HomeMy WebLinkAboutsewer lift station - Septic Pumping Slip - 136 BRIDLE PATH 6/2/2021 Commonwealth of Massachusetts RECEIVED
City/Town of JUN 0 2 2021
System Pumping Record -M MOFWKHANDOVER
Form 4 HEALM 6EPARTMWT
DEf 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 ght from 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 ck
City/rown State Zip Code
2. System Owner. f �
Name ('
Address(W different from location)
C40 Town State ^ r Code
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ❑ Septic Tank ❑ -riot Tan
S.
Other(describe): �i
4. Effluent Tee Filter present? ❑ Yes ❑ No 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. Locati ere contents-were disposed:
G L S:JP Lowell Waste Water
Sign We I Hsuf Date
tftrrn4.dor.-06/03 System Pumping Record•Page 1 of 1