HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 80 PHEASANT BROOK ROAD 7/19/2021 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record �OR�NPNp_vA'
r-
Form 4 Z� 0,HpEPpR�MEN
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 house, Left/re
ht rear of hour Left/right side of house, Left
Right side of building, Left/Right front of building, TT
Mg
�rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown Staten Zip Code
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) epttc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO 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 ere contents-were disposed:
.L S Lowell Waste Water
Signitute crHauleVDate
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