HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 371 SUMMER STREET 11/30/2020 : Commonwealth of Massachusetts RECENED
City/Town of
System Pumping Record
Form 4
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 bTh 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(Leff 'ght r o ho Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
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City/Town l State Zip Code
2. System Owner.
Name'
Address(if different from location)
CwTown
Telephone Number
B. Pumping Record
1. Date of Pumping Dam :e-p
Qu tity Pumped: s;allo
ns
3. Type-of system: ❑ Cesspool(s) tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Syst /
li cl—
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
ALL&P Lowell Waste Water
Sign We Haul Date
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