HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 BANNAN DRIVE 1/14/2021 Commonwealth of Massachusetts
UICity/Town of AN 14 2021
System Pumping Record , rI1RNDUVCR
.-F
Form 4 ;�pRrr�eNT
DEP has provided this form for use-by local Boards of Health. Other forms may be*used,but the
information-must be substantiagy 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:/Rig nt f hou Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Rignt trontOr uilding, Left/Right near of building, Under deck
Address
CityRown State Zip Code
2. System Owner. � f C�
Name' v
Address(if different from location)
CitylTown State Zip Code
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 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. Lo here contents-were disposed:
L S Lowell Waste Water
Signiture qt Hhui Date
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