HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 67 CRICKET LANE 1/14/2021 : Commonwealth of Massachusetts s1
kvCity/Town of BAN 14 2021
System Pumping Record nIngl„_ANCUVEF
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 tc)
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 g side f hous , Left
Right side of building, Left/Right front of building, Left/Right rear of b mg, Under
Address
City/rown State Zip Code
2. System Owner.
Name
Address(if different from location)
clown stat(C_> �-
Telephone Number
B. Pumping record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Dli§eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:�G��`�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ere contents-were disposed:
_L S Lowell Waste Water
Sign We cfHaulouDate
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