HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 192 STONECLEAVE ROAD 4/28/2021 Commonwealth of Massachusetts� zz
r�� �
_ City/Town of �pR 2 8?
System Pumping Record T Q?t
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: Left/Right front of house, Le�'Righ eer of houses Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left rear of building, Under deck
Address j 1 AA,"tv,
City/Town State Zip code
2. System Owner.
Name
Address(if different from location)
city/Town State; z i/Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 0-�§ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes EY'N-io� If yes, was it cleaned? ❑ 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:
.L Lowell Waste Water
SignAtule 9t Haul Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1