HomeMy WebLinkAboutseptic Tank - Septic Pumping Slip - 140 VEST WAY 5/17/2021 : Commonwealth of Massachusetts
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City/Town of
System Pumping Record MAY 17 207.1
Form 4 Tc
DEP has provided this form for us&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 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 eft g front f ous , Left/Right rear of house, Left/right side of house, Left 1
Right side of bui mg, Left/Rig rout of building, Left/Right rear of building, Under deck
Address
City/Town l� State Zip Code
2. System Owner. q„
Name'
Address(if different from location)
CitylTown Staten�� � Zip Code
Telephone Number
B. Pumping record r
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a_90 If yes, was it cleaned? ❑ Yes ❑ No
5. Conditiop of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location whe content%were disposed:
4svene
Lowell Waste Water
aul Data
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