HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 66 CEDAR LANE 7/6/2021 Commonwealth of Massachusetts , r
City/Town of �
System Pumping Record JUL 06 2021
` Form 4
�,•v 117D OF HEALTH
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/Right front of house, Left/Right rear of house L ►=rs'-i f ouse ft/
Right side of building, Left/Right front of building, Left/Right rear of building, c
Address / /` _ C f� at,/ 4^"v`T ��
City/Town SI'tate`J Zip Code
2. System Owner.
Name
Address(if different from location)
Cityffown State Zip Code
Telephone Number
B. Pumping Record
'agk
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Leo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System-
Ila
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
,L S. Lowell Waste Water
Sign a Haul Date
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