HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 85 SULLIVAN STREET 8/10/2020 RECEIVED
Commonwealth of Massachusetts
City/Town of AUG 1Ol
System Pumping Record TOWN HEALTH
DEP DEPARTMENT
R
Y p g HEALTH DEPARTMENT
Form 4
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
a
1. System Location: Left/Right front of house, Left/Right rear of house, e�Hig side of houses Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State Zip Code
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 01140 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. Loca' 9,,vhere contents were disposed:
Lowell Waste Water
ign a Haul Date
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