HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 FOSTER STREET 5/17/2021 Commonwealth of Massachusetts RECEIVE®
City/Town of MAY 17 ZOZi
System Pumping Record I
WEAForm 4
DEP has provided this form for us&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/Right rear of house,4 eft igKs—id e of hou eft 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under de= C
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State zi a
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 ❑-Ko- 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. Lqce#cq3qhere contents-were disposed:
G L#Haul
Lowell Waste Water
Sign Date
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