HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 163 SUMMER STREET 7/8/2021 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record
Form 4 � N pkNPRi R ANDDR
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,pefflfight ar ouse 'Left/right side of house, LeftRight side of building, Left/Right front of bul , eft/R-ig"Iff-r-e-a-r—of building, Under deck
Address
City/Town 1l State Zip Code
2. System Owner. CC
Name
Address(if different from location)
City/Town State Zip Code
s✓ C
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 to If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. 7G,
e ontents were disposed:
S. ' Lowell Waste Water
Sign a Haut Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1