HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 381 SUMMER STREET 10/5/2021 Commonwealth of Massachusetts RECEIVED
City/Town of OCT 0 5 2021
System Pumping Record TMMOFtdMHAlMVS
Form 4 WAJH DUWr," 1 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 hous�Rig rear of hou eft/right side of house, Left
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
Address C
City/Town State Zip Code
2. System Owner. PC
lc4VI (�
Name
Address(if different from location)
CiWown stater Zip Code
Sa - s's
Telephone Number
B. Pumping Record
1. Date of Pumping a I Quantity Pumped: I ��
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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. Location ere contents-were disposed:
G L S.P Lowell Waste Water
Sign a Haul Date
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