HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 191 GRANVILLE LANE 11/2/2021 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DER 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/ i ht front of house;Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front OT building, Left/Right rear of building, Under deck
Address
cityrrown State Zip Code
2. System Owner.
Name J 1�
Address(if different from location)
City/Town Stater � It 97 Zip Code
Telephone Number ��/
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ cesspoolM D_Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [a 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. Locationwhere contents were disposed:
Lowell Waste Water
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Sig Data
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