HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 180 GRAY STREET 9/13/2021 Commonwealth of Massachusetts R�CE�VED
City/Town of SEA A U0
System Pumping Record
Form 4
DEf has provided this form for use-by local Boards of Health. Other forms may *used,but the
information,must be substantiW the same as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh 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/ of�e, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address t �^ �-
CftyRo �J State Zip Code
2. System Owner.
7
Name
Address(if different from location)
Cilyfrowns��.�- 2� 43code
Telephone Number
.B. Pumping Record
1. Date of Pumping oa�e Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L7 No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S Lowell Waste Water
sign we PlaulmuDate
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