HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 155 DUNCAN DRIVE 1/14/2021 : Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for usez 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 to
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, Left/ ht side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under dec
Address i �
CiWrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrrown stater zCode
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 LiO 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. Location a contents were disposed:
GL S. Lowell Waste Water
Sign a Haul Date
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