Loading...
HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 41 CROSSBOW LANE 8/16/2021 _ Commonwealth of Massachusetts RECEIVED City/Town of AUG 16 2021 System Pumping Record Form 4 fiQN ©TH R DEPARTMENT 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 hous Le . lghtgtear-ofhouse, Left/right side of house, Left Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address L� l CA—OGS Dty/Town State Zip Code 2. System Owner. Name Address(if different from location) City/Town State Zip Telephone Number B. Pumping Record 1. Date of Pumping12 Quantity Pumped: Dam Gallons 3. Type of system: ❑ Cesspool(s) a-teptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes L_f 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. 7G, here contents were disposed: S. Lowell Waste Water g���� Signitule 4 Haul Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1