HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 149 BRIDGES LANE 10/5/2021 RFczlvzo
Commonwealth of Massachusetts 1c, 0
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System Pumping Record MENT
Form 4
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 housePing,
g t�othouse,, eft/right side of house, Left
Right side of building, Left/Right front of boilftilding, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: 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:
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6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati wh contents were disposed:
G L S Lowell Waste Water
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Sign a Haul Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1