HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 96 ABBOTT STREET 8/16/2021 : Commonwealth of Massachusetts RECEIVED
City/Town of AUG 16 2021
System Pumping Record TON(t4OFWRTHANDMER
Form 4 HEALT4 VE'R ENT
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 bTh 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/ . ht rear of hous Left/right side of house, Left
Right side of building, Left/Right front of building, Left r of building, Under deck
Address 1^Jn`, '
city/Town `) J State Zip Code
2. System Owner. t
Name
Address(if different from location)
cWrown Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition f System: �JC q
U v\
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio contents were disposed:
/4ZA Lowell Waste Water
signWe0bulmuDate
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