HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 136 SAW MILL ROAD 9/2/2020 Commonwealth of Massachusetts RECEIVED
= City/Town of SEP 2 �p20
System Pumping Record
Form 4 TO HEALTH DEPARTMENT R
DEP has provided this form for usez 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/Right rear of house,(AirigfiFC1de of hou , 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. 0 �
Name
Address(if different from location)
City/TownZi3 e
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Qua 'ty Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No if yes, was it cleaned? es ❑ No
5. Condition of System-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7.jSignAtute
here ontents were disposed:
Lowell Waste Water
cf Haul Date
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