HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 145 CRICKET LANE 5/17/2021 : Commonwealth of Massachusetts
91 City/Town of R
System Pumping Record Mph 202�
Form 4
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/Right rear 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 45—Z/ �.
Cityfrown State Zip Code
2. System Owner.
Name' l
Address(if different from location)
City/Tawn State /� ,�Code
Telephone Number
B. Pumping record
1. Date of Pumping Date ���eptic
ty Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
b � �
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. 7GL
e contents-were disposed:
S. Lowell Waste Water
SignkWe qt Haul Date
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