HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 12 FARNUM STREET 11/2/2021 Commonwealth of Massachusetts
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 house, Left/Right rear of hous. &'agl
g de ous eft
Right side of building, Left/Right front of building, Left/Right rear of b c
Address
CityfTown c�- vp State Zip Coda
2. System Owner.
Name
Address(if different from location)
CityfTown State ` i Code
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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 No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson_ Enterprises inc
Company
7. Lo here contents were disposed:
G L S. Lowell Waste Water
Sign a Haul Date
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