HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 42 SPRING HILL ROAD 9/29/2021 Commonwealth of Massachusetts
9 City/Town of
System Pumping Record
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 hourea f hou , Left/right side of house, Left I
Right side of building, Left/Right front of%beingiiL'et, g t rear of building, Under deck
Address � � � �C� o �
City/rown state toCotle
2. System Owner.
Name"
Address(if different from location)
CitylTown State �C Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2.Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) peptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a4fo_ If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locatiql wnet#contents-were disposed:
G L S Lowell Waste Water
Sign a qt HaLderu Date
t5ibm-A.doc•06/03 System Pumping Record•Page 1 of 1
'. , x - _
14..E - ?-�:� ... ,s.. � � Yi t.^{i::.M�w'd• .
i
�` - •� ..
.. 1 .. _.
_ ., ti..
,. ,. . . ,. s< �
a��. ... _ ..: _ _ _ __ _
_ __
.. ... .µ...� ... _. ��. _ \` � ���' ,�.�"?����`rya .. .. -- �'�'..� ..
s
�.a�r
,\
`\ '
-� '��