HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 24 DEER MEADOW ROAD 4/9/2021 :1\_ Commonwealth of Massachusetts
City/Town of yl
System Pumping Record APR 0 2021
Form 4 HgEALTH
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/ ' r of hous , Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Rig of building, Under deck
Address
ClyRown State Zip Code
2. System Owner.
Name'
Address(ir different from location)
cWrown Stater Z
c z_ 6p Qt
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? es ❑ No If yes, was it cleaned? [jY99__6 No
5. Condition of stem:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
S: Lowell Waste Water
USA.-
SignWe }fiul Date
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