HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 338 BERRY 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 used,but the
information,must be substantially the two 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 L�kight ft/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2 System Owner.
Name'
Address(if different from location)
cityffawn state s Y -� r71 �,ip e
Telephone Number
B. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes EJ14 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By.-
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locati re contents-were disposed:
G L S Lowell Waste Water
1--W a- A.
signkje 9f HaulffluDabs
ftrm4.doa 06103 System Pumping Record•Page 1 of 1