HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 83 LIBERTY STREET 11/2/2021 :N Commonwealth of Massachusetts
City/Town of
System P-umping 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 it .'6, Left/Right rear of house, Left/right side of house, Left
Right side of building, Leff7-R g t front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State `pap code
Telephone Number +� _
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ado 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. Locatio ogre contents-were disposed:
77_L S. Lowell Waste Water
SignAtute 4 Haul Date
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