HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 45 TURTLE LANE 5/17/2021 :�L\ Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe 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 forth 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 ig fron of house?Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right�Todt�fbuildirig, Left/Right rear of building, Under deck
Address
City/Town C State Zip Code
2. System Owner.
Name"
Address(if different from location)
C�ty/Town dip Code 9
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) tc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. 7.G,
a contents-were disposed:
S Lowell Waste Water
c3
Sign We 9t Haul Date
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