HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 120 GRANVILLE LANE 7/1/2020 RECEIVED
: Commonwealth of Massachusetts JUL o 1 2020
City/Town of
DOVM
System Pumping Record �HEALLTH DEPARTMENT
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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 rear of house side of house eft
Right side of building, Left/Right front of building, Left/Right rear of 1512g.
Address
CRY/Town State Zip Code
2. System Owner.
Name.
Address(if different from location)
City/Town s� p
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) 0-ge-p—ic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0--No- If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 4,
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents-were disposed:
Lowell Waste Water
_Q
Sign aqt HaulwU Date
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