HomeMy WebLinkAboutSeptic Pumping Slip - 44 EQUESTRIAN DRIVE 2/8/2016 1
Commonwealth of Massachusetts
= City/Town of
Systenm 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 LocationPingg0jeft Rig ro t f do se, Left/Right rear of house, Left/right side of house, Left/
Right side of bull /Rich ro o uilding, Left/Right rear of building, Under deck
Address
L-C L ✓
Cityrrown State Zip Code
2. System Owner.
Name*
Address(if different from location)
City/Town ' State
t
Telephone Number ` d
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B. Pumping ,Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type•of•system: F-1 Cesspool(s) is Tank [I Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste .:
6.- System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location-Where contents were disposed:
.L S: Lowell Waste Water
Signitufe ct Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
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