HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 61 ESSEX STREET 7/22/2020 :_C\_ Commonwealth of Massachusetts RECEIVED
_ City/Town of JUL 2 2 20211
System Pumping Record
OFHAWWR
Form 4 NEWNSEAMM
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/16 t rea of hou�;Left/right sid ouse, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, ec
Address
City/Town ( State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State Zip de
C -�� -- G
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) 9-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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. Lo iol -where contents-were disposed:
A
gHaulwU
Lowell Waste Water
Date
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