HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 151 STONECLEAVE ROAD 7/1/2020 Commonwealth of Massachusetts RECEIVED
City/Town of JUL o 1 202o
System Pumping Record TM Form 4 �NmH P
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/144ht rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
-
Cityrrown State Zip Code
2. System Owner.
�G
Name
Address(if different from location)
Cityfrown State Code
>r s
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. LojLS.
where contents were disposed:
G Lowell Waste Water
Sign Haul Date
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