HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 742 WINTER STREET 7/6/2021 Commonwealth of Massachusetts EIVED
City/Town of JUL 061021
� System Pumping Record
Form 4 C,+aM 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/ fight front of hous eft/Right rear of house, Left/right side of house, Left
Right side of building, Left fight front of building, Left/Right rear of building, Under deck
Address .f`� p a W
City/rown State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown State Z' Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) U Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes El-No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of st
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio ere contents-were disposed:
G L S Lowell Waste Water
Sign a Haul Data
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