HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 173 BRIDGES LANE 6/7/2021 Commonwealth of Massachusetts RECEIVED
_ City/Town of SUN p 7 ZO
System Pumping Record �NORTHANO
Form 4
DEP has provided this form for us&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 tf�j ght 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 t J-? 3 � ` ' �v `_ c�
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State �Zi�de
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 EI-148 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. Location-wheLe contents-were disposed:
Lowell Waste Water
Sign a Haut Date
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