HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 103 LOST POND LANE 7/6/2021 .Yb\- Commonwealth of Massachusetts
City/Town ofINU
System Pumping Record JUL ns 2021
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 Ri t rear of house Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address �Q
city/Town State Zip Code
2. System Owner.
Name.
Address(if different from location)
Ciiynywn
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 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:0
6. System Pumped By.
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocatiomzAwe contents-were disposed:
G LS-Q Lowell Waste Water
Sign aqtHIulwDate
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