HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 116 SHERWOOD DRIVE 5/18/2020 : Commonwealth of Massachusetts
t alaffigammem City/Town of MAY 18 2020
System Pumping Record
Form 4 TOVV14 OF No�zTl��lyl�vv�:
t4,EAI.TH DEPARTMENT
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 forrim 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 house, LefQ
Right rear of hous , Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Rig t eo building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(ir different from location)
CitylTown state
OG� _ � ( e
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: -'
Gallons
3. Type-of system: ❑ Cesspool(s) t_Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D_No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: V(k C,/� 4,Z-L �Z_
6. System Pumped By:
Neil.Bateson F5821
Name Vehide License Number
Bateson Enterprises Inc
Company
7. Lo i e contents-were disposed:
L S Lowell Waste Water
to
Sign a Haul p
tftrm4.doc-06103 System Pumping Record•Page 1 of 1