HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 25 HOLLOW TREE LANE 5/17/2021 : Commonwealth of Massachusetts tECEIED
_ City/Town of MA' 17 MI
System Pumping Record rawtioi roRr�ArGOv
Form 4 HF-ALTH DEPARfPd1:1°IT
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 Locatio # Righ ont of hous Left/Right rear of house, Left/right side of house, Left
Right side of bui! Ing, Left/Right fron o uilding, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner. A-v-\"
Name'
Address(if different from location)
CiVrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) [$.optic 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 contents-were disposed:
�L S Lowell Waste Water
Signitute Haul Date
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