HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 337 HILLSIDE ROAD 9/13/2021 Commonwealth of Massachusetts RECEIVED
= City/Town of 21
System Pumping Record oFNORsr+AN�vER
Form 4 TONIA LTH DFpAFtTMENT
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�, Le4-'-/-r1gjCsee-`Wf use,Left/
Right side of building, Left/Right front of building, Left/Right rear ofding, Under deck
Address
(j-k-
> -
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CityJTown S . Zp Cod���,.7_��^
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type W system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LJ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System•p�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises inc
Company
7. Location where contents-were disposed:
L S: Lowell Waste Water
Sign a Haul Date
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