HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 65 CEDAR LANE 7/6/2021 Commonwealth of Massachusetts
City/Town of JUL 6 2021
System Pumping Record 710ARD OF HEALTH
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,&Right ear ous. Left/right side of house, Left
Right side of building, Left/Right front of bul ing, L ` ear of huiidding, Under deck
Address
Cityffown State Zip Code
2. System Owner.
Name
Address(f different from location)
City/Town State Zip Code
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 Leo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: i��A� 00"cl"� �t
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo re contents-were disposed:
G Lowell Waste Water
NaA.
Signitule f Haul Date
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