HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 130 CHRISTIAN WAY 1/14/2021 . Commonwealth of Massachusetts
City/Town of JAN 14 2021
System Pumping Record
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 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 �of , Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Citylrown State Zip Code
2. System Owner l.�t _l ksr
Name' �J
Address(if different from location)
CitylTown iD C � r `7(sl Code
Telephone Number `'C /
B. Pumping record
t a-
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 o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
G. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo a ontents{were disposed:
CAI_S Lowell Waste Water
sign we C1 Hhulefu Date
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