HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 138 OLD CART WAY 4/28/2021 Commonwealth of Massachusetts _4;
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City/Town of
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System Pumping Record rowNo>=NOaT 202�
Form 4 HEA �1—�H
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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: Left/Right front of house, Left/Right rear of house big sid�6qffhobse ft 1
Right side of building, Left/Right front of buiidirig, Left/Right rear of b`ul7ding, Unde
Address ( (—// �1
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
city/Town State Cod
Telephone Number
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) �ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ YesQ1lo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
G L S Lowell Waste Water
Sign a Haul Date
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