HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 49 ORCHARD HILL ROAD 7/6/2021 Commonwealth of Massachusetts
City/Town of JUL o 6 2021
System Pumping Record
Form 4
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 I Right rear of house, Left/right side of house, Left I
Right side of building, Left/Right rant o bui dilig Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner. A Al
Name
Address(if different from location)
City/Town Stat r e
`- " C�
Telephone Number
B. Pumping Record C(�
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) tic 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. L=LS-P
rms contents were disposed:
Lowell Waste Water
Sign a Htl ulevDate
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