HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 24 FARNUM STREET 7/6/2021 : Commonwealth of Massachusetts E EC Lim �
City/Town of
System Pumping Record JUL 06 2021
Form 4 `L.70ARD OF HEALTH
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 housed"Igh r o r house Left/right s' of house, Left 1
Right side of building, Left/Right front of building, Left/ building, nder
Address
CRylro" `( State Zip Code
2. System Owner.
Name'
Address(f different from location)
CWrown
l
Telephone Number
B. Pumping Record
1. Date of Pumping Pumped:
Date 2. Quantity Pd:
Gallons
3. Type-of system: ❑ Cesspool(s) 0-S-6-1;tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes to If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: J� p
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
. ' Lowell Waste Water
Signkie 4tHAUlMU Date
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