HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 7 SOUTH CROSS ROAD 9/7/2021 RECE�vED
Commonwealth of Massachusetts
MoMMMOMMCity/Town of 2021
OF WFO A% t
System Pumping Record 10H zHpEPaR�M"
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, Left/Right rear of hous.kC&J.:lig 5_1Teqfhou_sjs, Left1
Right side of building, Left/Right front of building, Left/Right rear of building, Un er
Address � zs
Citylrown State Zip Code
2: System Owner.
Name'
Address(if different from location)
CitytTown
Telephone Number
B. Pumping Record
1. Date of Pumping ;:eptle
Qu� ti Pumped:
Dam ty p Gallons
3. Type-of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System` ,� � ��C.!-�_ q cam,
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents-were disposed:
�L S Lowell Waste Water
Sign We cfHaLdwUDate
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