HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 32 DEER MEADOW ROAD 9/13/2021 Commonwealth of Massachusetts ocox-D
City/Town of 1
3 02
System Pumping Record SY 1
Form 4 '(pWN��H p PPR MEND
DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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 R�ofeft/right side of house, Left/
Right side of building, Left/Right front of building, Llding, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name I 1
Address(if different from location)
Cityffown State Zip Code
5?�3— h tfy-a- (o
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ly'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati where contents were disposed:
G L S. Lowell Waste Water
Sign a Haul Date
t5form4.doc-06/03 System Pumping Record•Page S of 1