HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 87 SUGARCANE LANE 7/1/2020 Commonwealth of Massachusetts RECEIVED
JU!_ 01 2070
= Cityff own of
System Pumping Record T0`""'` ' '��
y p g HEALTH Da, >rr
Form 4
s
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 kAi ht rear of house,Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rlgh raw of building, Under deck
Address \ j
City/Town State Zip Code
2 System Owner.
Name
Address(if different from location)
Citylrown State j�� Zip de
(-4l-('- �'?�o
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? ❑ Yes D.-No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syste
6. System Pumped By:
Neil.Bateson _ F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where_contents were disposed:
Lowell Waste Water
M aA.
Signiqe cfl-laulwU Date
tftrm4.doc•06/03 System Pumping Record•Page 1 of 1