HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 240 ABBOTT STREET 4/9/2021 a n , ,{
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: Commonwealth of Massachusetts 2021
City/Town of APR o b
System Pumping Record b tj I���� 7 "
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 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:09 i ro t o�=Rildifig,
, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right ro Left/Right rear of building, Under deck
Address
City/Tom state Zip Code
2. System Owner.
Name' 1
Address(ir different from location)
CitylTown State `�Q C j e
Telephone Number
B. Pumping Record
0
1. Date of Pumping o� — Quantity Pumped:
3. Type-of system: ❑ Cesspool(s) 018 ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ailo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location whwo contents-were disposed:
Lowell Waste Water
Sig a Haul Date
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