HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 178 BRIDGES LANE 1/14/2021 Commonwealth of Massachusetts
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City/Town of JAN 1 4 ?Q?1
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System Pumping Record
Form 4
DEf has provided this form for use-by local Boards of Health.Other forms maybe'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 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: Left/Right front of house, Left/Right(jjFbf house,� a right e Vie. /
Right side of building, Left/Right front of building, Left/Right rear of building, Under eck
Address
Citylrown �- state Zip code
2. System Owner.
Name"
Address(if different from location)
City/Town State 4D Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date I 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.Bateson F5821
Name Vehide License Number
Bateson Enterprises Inc
Company
7. Locatio re contents-were disposed:
LL.S-P Lowell Waste Water
signAwe it Haulau Date
t5formCdocr 06/03 System Pumping Record•Page 1 of 1