HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 155 CHRISTIAN WAY 10/12/2021 r a'•
: Commonwealth of Massachusefts
01
City/Town of NpR�H PNpU 1
System Pumping Record �pH�`NpEppR�MEN
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
iocal 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 house, Left/right side of house, Left/
Right side of building, Le ig t ronTof building, Left/Right rear of building, Under deck
Address
Citylrown uP code
2. System Owner.
Name
Address(if different from location)
CiWTown State Zip Code
- C(o� - (cD'_C
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 Io If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Purnped By:
F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where content&were disposed:
Lowell Waste Water
Sign acf Haulez Date
5form4.dov 06103 System Pumping Record•Page 1 of 1