HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 64 SUGARCANE LANE 4/9/2021 Commonwealth of Massachusetts M ;k-=
City/Town of
3
System Pumping Record APR 0 2021
Form 4 -M ")F !
DEP has provided this form for use=by local Boards of Health. Other forms may be'used, but the
information-must be substantially the tame 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/ik%mt front of house, Left/Right rear of house, Left./right side of house, Left I
Right side of building, Left/RighfTr&it of building, Left/Right rear of building, Under deck
Address < tu
City/Town state Zip Code
2. System Owner.
Name'
Address(if different from location)
cityfTown state Zip Code
(T
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system, ❑ Cesspool(s) 0-Septic Tank F-1 Tight Tank
0 Other(describe):
4. Effluent Tee Filter present? [:] Yes If yes, was it cleaned? Ej Yes ❑ No
5. Condition of System
6. System Pumped By:
Neil Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents,were disposed:
Lowell Waste Water
C
f
Sign eH'aulNu Date
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