HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 62 BANNAN DRIVE 1/14/2021 RECEIVED
: Commonwealth of Massachusetts BAN 14 NZI
ulpCity/Town of
System Pumping Record �`°'�'�® NORTH�oc�V�t
Form 4
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 autho ft.
A. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ^
CRyRown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTown SAC%5 •J `C ��Code
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped:
Gallons
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 VeNide License Number
_B_ateson Enterprises Inc
Company
7. Location where contents-were disposed:
G L S Lowell Waste Water
Sign a Fi�ul Date
15form4.doo-06/03 System Pumping Record•Page 1 of 1