HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 72 SAW MILL ROAD 7/1/2020 Commonwealth of Massachusetts RECEIVED
City/Town of JUL 0 1 lo;
System Pumping Record TOWN0FWR7"AUWER
Form 4 ACTH 0EP*MW:qT
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 houseigh ear of house, ft/right side of house, Left/
Right side of building, Left/Right front of building, Left/ oTbuilding, Under deck
Address ( C� 4
CyTown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown State Zip�de�
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) D-S'eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: Vr CA i- 1 01
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo e contents-were disposed:
G L S. Lowell Waste Water
4--d _
Sign a Haul Date
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