HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 VEST WAY 9/7/2021 : Commonwealth of Massachusetts RECEIVED
City/Town of SEP 0 7 2021
System Pumping Record TOWN
Form 4 HEALTH 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 lq3kht ont of house, Left/Right rear 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
CWTown Lj State Zip Code
2. System Owner. UJ
`z4"t-
Name
Address(if different from location)
City/Town State Zip
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) [peptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a-90 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
_L S Lowell Waste Water
jSignAtuFe Hau( Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1