HomeMy WebLinkAboutSewer Lift Station - Septic Pumping Slip - 465 CHESTNUT STREET 8/16/2021 RECEIVED
Commonwealth of Massachusetts lit/;lil/;3 7 61202,
City/Town of
System Pumping Record T�oHEEPgRTNDDVER
y p 9 MENT
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, eft �rea;rdf house`Left/ri ht side of house, LeftRight side of building, Left/Right front of bur tng, Left/ rear of building, Under deck
Address
City/Town State Zip Code
2, System Owner.
Cc-)
Name
Address(if different from location)
CityiTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑ S2ptic Tank ❑ Tight Tank
0-6—her(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No 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. Location where contents-were disposed:
G L S. Lowell Waste Water
4-SSig—nAtjujeVVHaul Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1