HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 261 REA STREET 9/2/2021 Commonwealth of Massachusetts � �{
City/Town of SEp p 2 2021
System Pumping Record
Form 4 j�O AR EAC
d
DEP has provided this form for umby 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 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 eft h nt oChou Left/Right rear of house, Left/right side of house, Left/
Right side of butT l , Left/Right lding, Left/Right rear of building, Under deck
Address
City/town State Zip Code
2. System Owner-
Marne'
Address(W different from location)
CitylTovm �� Zip Code
J �— o
Telephone Number
6. Pumping Record �I ,
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 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. Locati here contents-were disposed:
CAL Lowell Waste Water
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