HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 545 SHARPNERS POND ROAD 10/5/2021 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping Record TH
OF NCR
H� VER
Form 4 TowN LTH DEPART 0 T
�,.
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 g si Left
Right side of building, Left/Right front of building, Left/Right rear of ing, Un er ec
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
citylTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Q--8€ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0 o 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. Location where contents,were disposed:
Lowell Waste Water
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SignAtute 4 HtuleV Date
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