HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 146 DEER MEADOW ROAD 1/21/2021 : Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for umby local Boards of Health. Other forms maybe*used,but the
information must be substandaily the same as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh 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: Le t front of hou , Left/Right rear of house, Left/right side of house, Left 1
Right side of building, e g front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name.
Address(if different from location)
City/Town Zip Code
Telephone Number
6. Pumping Record Q
1. Date of Pumping date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) 0,8 ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? �❑ No If yes, was it cleaned? QY-e&❑ No
5. Condition of System,
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location ere contents-were disposed:
_L S Lowell Waste Water
Sign We f I-lauleit Date
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