HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 295 REA STREET 10/7/2020 Commonwealth of Massachusetts RECEIVED
City/Town of OCT 0 7 2020
System Pumping Record Tp�VNpF I)EPARN0
Form 4 HEALIH DEPAR"fMENT
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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/R�_� rear of houUss6, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Rig t rear of building, Under deck
Address �" � I-------�-4 f ��
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State, � \ ..dip-Code
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? D-�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. Location w4ere contents were disposed:
Lowell Waste Water
Lc- - �F mow
Sign We OaulerUDate
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