HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 164 MILL ROAD 4/28/2021 : Commonwealth of Massachusetts e_r `�"f.
City/Town of AN 2 8 2021
System Pumping Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may beused, 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 hous. e /l'' side of hous Left 1
Right side of building, Left/Right front of building, Left/Right rear of g, Un er ec
Address � R
CWrown lam' State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) [3-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ej-No 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. ;Loq0okwRWe contents were disposed:
G L MS. , Lowell Waste Wa#er
(Sign Date
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