HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 41 CROSSBOW LANE 5/18/2020 Commonwealth of Massachusetts Ems':
_ City/Town of MAY 18 ZOzo
System Pumping Record T��,,Ncl�;()IMH/�hlDU EP
Form 4 :PARTMENT
DEP has provided this form for use=by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of hou , 4A/kight rear`of hou�eft/right side of house, Left/
Right side of building, Left/Right front of bul ding, Left/Right rear of building, Under deck
Address
C'rty/Town (' State Zip Code
2. System Owner.
�j
Name
Address(if different from location)
Citylrown State, Zip Em�e
Telephone Number
B. Pumping Record _
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Q,Seotfc'Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ' �_
i�� �� L
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
G L Lowell Waste Water
r
9—�s -
Signitute f Haul Date
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