HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 31 BRIDGES LANE 4/28/2021 Commonwealth of Massachusetts RECEIVED
City/Town of APR 2 8 20?1
system Pumping Record
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.fhis 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/ gr &—i We of hous Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under dec
Address -:-:5
City/--town state Zip Code
2. System Owner. 0
Name
Address(if different from location)
City/Town sip Code
J -7—L4
Telephdne Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 3--N�o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ��✓���� C�� � � <-����C
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location-ire contents were disposed:
Lowell Waste Water p
SignAtute 9t HauleV Date
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