HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 60 LONG PASTURE ROAD 5/17/2021 : Commonwealth of Massachusetts R���'���D
lugCity/Town of
System Pumping Record
Form 4
DEP has provided this form for um.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 houseA:WW9 side f hous Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner
Name'
Address(ir different from location)
CilylTown
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 nlgo 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. Lo ere contents-were disposed:
TLowell Waste Water
t N.
Sign We 9t Haul Data
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