HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 181 LACY STREET 4/28/2021 Commonwealth of Massachusetts RECEIVED
_ City/Town of APR 2 8 2021
System Pumping Record
TOWN
Form 4 HEALTH DEPARTMENT
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 fors 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/ ' fit rear of hou�a?Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
citynown State _lip Code
u - 5
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes D-40 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 re contents-were disposed:
7GL Lowell Waste Water
SignAqe qt HaulwU Date
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