HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 72 WINDSOR LANE 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"rd Righ ear�rearuo
Left/right side of house, Left/
Right side of building, Left/ Right front of but ing, Left/Righuilding, Under deck
Address ` '
City/Town w, State Zip'C_ode
2. System Owner.
d
Name
Address(if different from location)
Citylrown State Zip Code
Telephone Number
B. Pumping Record oc�
1. Date of Pumping Date ,_.,, 22. Quantity Pumped: 6aiions
3. Type of system: ❑ Cesspool(s) 9-Septic 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,
I� r
U V . �� C F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where content.%were disposed:
Lowell Waste Water
Sign a aul V Date
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