HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 600 FOSTER STREET 7/7/2021 Commonwealth of Massachusetts �ECENED
City/Town of
System Pumping Record QRTHpNDC
Form 4 10 Ham`H pEPP'F'10 I
DEP has provided this form for use-by local Boards of Health. Other forms may 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 ar of house Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/rown State Zip Code
2. System Owner
Name'
Address(if different from location)
CivTown
Telephone Number
B. Pumping Record
1. Date of Pumping oat 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) 01-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? �❑ No If yes, was it cleaned? •. _ Yes ❑ No
5. Conditio n tem-
6. System Pumped By:
Neil.Bateson _ F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location ntentsr were disposed:
L S Lowell Waste Water
Signk4e qt HbuleiV Date
t5fom4.doc-08/03 System Pumping Record•Page 1 of 1