HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 96 FARNUM STREET 4/9/2021 : Commonwealth of Massachusetts
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City/Town of - r Ir r
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System Pumping Record APR o 2021
Form 4
DEP has provided this form for use--by local Boards of Health. Other forms may be'usbd,
information,must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the bTh 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/&-ht near of house Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town �- State Zip Code
2. System Owner.
L v ��
Name'
Address(if different from location)
CWrown State Code
� - 7
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o 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. Location where content&were disposed:
��,S Lowell Waste Water
'V/�` `A-_Ex�m_�
Sign aqtHhulervDate
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