HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 DEER MEADOW ROAD 9/2/2020 Commonwealth of Massachusetts RECEIVED
_ City/Town of
System Pumping Record ` 'ZO` (i
Form 4 TOWN,TH DEPAR VENT
OVIR
HF.A
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, ei Rig rear�se� Left/right side of house, Left 1
Right side of building, Left/Right front of bui Trig, Left rear of building, Under deck
Address A)Oc�`aA
C4frown State Zip Code
2. System Owner.
Name"
Address(if different from location)
City/Town State" Zip Co*
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. Loawfi �ontents"were disposed:
Lowell Waste Water
Sign a Haul Date
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