HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 MARIAN DRIVE 5/18/2020 : Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
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 house, Left Right;�_s�sleXeft./right side of house, Left/
Right side of building, Left/Right front of building, auilding, Under deck
Address
Cityfrown State Zip Code
2. system owner:
Name'
Address(if different from location)
City/Town State s G — a
Telephone Number
B. Pumping Record _
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? No
5. Condition of SysterrV ��
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati ere contents were disposed:
G L S Lowell Waste Water
Bz6a_o-�� t)
Signit4e Haul Date
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