HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 7 INGALLS STREET 10/5/2021 Commonwealth of Massachusetts RECE�
City/Town of VEo
System Pumping Record OCT 05 20�1
Form 4 "OWNOFNORTH/ar _
• HEALTH D-p
DEP has provided this form for use,by local Boards of Health. Other forms may'69%sed, 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 foam 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 houses j;_ 4igh Ide of ho su .eft
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address ;—7 A—�o—
Z--o—f—rown State Zip Code
2. System Owner. Qc-cc-��( Cl'-'Cj!�'
Name
Address(if different from location)
City/Town State,
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 ENO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates-on _ F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location w re contents were disposed:
L S. Lowell Waste Water
q a
Sign a 4-HauleV Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1