HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 261 BRIDGES LANE 1/14/2021 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping Record JAN 14 2021
Form 4
—RYH ANIDOVEt
DEP has provided this form for use-by local Boards of Health. Other forms may.babsed,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, e
right oused Left
Right side of building, Left/Right front of building, Left/Right rear of building, Un raaix
of h
Address c=)Ic (-
City/Town State Zip Code
2. System Owner. A
Name
Address(if different from location)
CylTown State r� �t ,'Tp�da
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a-14�0 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. Locatio ere contents-were disposed:
G L S: Lowell Waste Water
Sig a Haut Date
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