HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 11 BRIDGES LANE 11/19/2020 :� Commonwealth of Massachusetts RECEoVED
. City/Town of
System Pumping Record
Form 4 T N OF NpEPA maAl R
C H�LTH
DEP has provided this form for use=by local Boards of Health. Other forms may '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 t Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Right front of building,Left If ght-rear of building, Under deck
Address
Cityfrown state Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown State- Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ( I < < 6 2_ antity Pumped: '
Date 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. Location where contents-were disposed:
G L S Lowell Waste Water
A
SignAture 9t Haulexu Date
,5form4.docr 06/03 System Pumping Record•Page 1 of 1
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