HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 76 GRANVILLE LANE 11/30/2020 :N Commonwealth of Massachusetts RECEIVED
City/Town of NOV 3 0 2020
System Pumping Record
Form 4 N A.WOVER
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 House, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
cityRown State Zip Code
2. System Owner.
Name'
Address(if different from button)
Telephone Number
B. Pumping Record
1. Date of Pumping Date�✓ 2. GallonsQu ty Pumped:
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L"fionwe content were disposed:
Lowell Waste Water
was)).
SignAWe Haul Date
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