HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 54 VEST WAY 6/14/2021 Commonwealth of Massachusetts
RECEIVED
w City/Town of jUN 14 NZI
System Pumping Record TOHNLTHDRIH"" OV R
Form 4
EpARTmENT
DEP 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/Right front of hous E�/-high ea of house,'Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Rig rear o building, Under deck
Address
city/Town l� w�state Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State- ZilzCode
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 DIN If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: 14,
t-
6. System Pumped By.
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents,were disposed:
,L Lowell Waste Water
Signitule fHauieVDate
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