HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 312 FOSTER STREET 6/14/2021 : Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record
Form 4 ,)KTrtnr� M
sc�n -.
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 foram,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
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
CWrown
Telephone Number
.B. Pumping Pecord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) G is Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes DING- If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
N/d
6. System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contentewere disposed:
�L S Lowell Waste Water
Sign a hlh Date
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