HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 190 BRIDGES LANE 10/12/2021 Commonwealth of Massachusetts RECEIVED
City/Town of 00Ao
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System Pumping Record 0FWg1k1ANovt
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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 douseXeft'/'xRigh ar of hou , _eft/right side of house, Left/
Right side of building, Left/Right front of bulidirig, Left/Right rear df building, Under deck
Address
C4frown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown 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 ZkKO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Wast ater
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Sign a ct Hauled Date
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