HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 JAY ROAD 11/30/2020 Commonwealth of Massachusetts RECEIVED
City/Town of NN 3 0 2020
System Pumping Record To pFNOR,H,wooVER
Form 4 HE�MLTH DEPARTMENT
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 k�iqht front of houseLeft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right rant of building, Left/Right rear of building, Under deck
Address '--4A
Civrown state Zip Code
2. System Owner.
Name
Address(f different from location)
City/Town Stat
e-:�) `� --�d- Zi 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? ❑ Yes 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:
Lowell Waste Water
SignAtufe ctHaulerUDate
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