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HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 100 FOSTER STREET 11/2/2021 Commonwealth of Massachusetts kvCity/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 house,Leff/rig a fuse; Left Right side of building, Left I Right front of building, Left/Right rear of building, Un er eck Address Cityrrown State Zip Code 2. System Owner. Name Address(if different from location) CitylTown Sta Zip Code Telephone eeSNumber B. Pumping Record C© 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Q-Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ©--No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: L-P-� V-A-74zrlk� 6, System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Loc�'en where content&were disposed: G L S Lowell Waste Water (C) -- - SignAtule I Haul Date t5form4.doa 06/03 System Pumping Record•Page S of 1