HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 99 HAY MEADOW ROAD 10/5/2020 �FcFi�
Commonwealth of Massachusetts ro ��r
= City/Town of
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System Pumping Record FpgRr"0��
Form 4 '� FR
DEP has provided this form for us&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, Left/ ht side of house, ft
Right side of building, Left/Right front of building, Left/Right rear of building, Under ec
Address
P �_ -
CRY/Town '01_ State Zip Code
2. System Owner. ,
Name
Address(if different from location)
City/Town State Zi de
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 Ea No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: CJ
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lq�on-wb_ contents-were disposed:
MS. / Lowell Waste Water
Sign Date
t5fbrm4.doc-06/03 System Pumping Record•Page 1 of 1