HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 131 GRANVILLE LANE 11/12/2020 : Commonwealth of Massachusetts REcelveo
City/Town of
System Pumping Record �� �2 20?0
Y p g HEAOHNEPAHAN R
Form 4 0 �v
RTMENTE
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 douse, Left/Right rear of hous , L eftRight side of building, Left/Right front of building, Left/Right rear of ulid'tng,fng��
Address ` �
Myrrown 1 I state Zip Code
2. System Owner.
Name'
Address(if different from location)
CityfTown Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping gate ��e
Quanti Pumped: Gallons
3. Type of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: A_brvk�d
l
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location a contents-were disposed:
G L S Lowell Waste Water
Sign We Haul Date
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