HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 HOLLOW TREE LANE 4/12/2021 : Commonwealth of Massachusetts RECFIVED
City/Town of �Pg 2 2021
System Pumping Record TOOFNORP ,% NTR
Form 4 •TM
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 to
the local Board of Health or other approving authority.
A. Facility Information
1. System Locatio • ems/ 'ght of lious , Left/Right rear of house, Left/right side of house, Left 1
Right side of bu , Left/Rig of building, Left/Right rear of building, Under deck
Address
My/Town State Zip Code
2. System Owner.
Name'
Address(d different from location)
CitylTown State p e
Telephone Number
B. Pumping Record
1. Date of Pumping �ai3e 2 Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a_ko 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 ontents-were disposed:
G L S Lowell Waste Water
Sign a Fiaul Date
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