HomeMy WebLinkAboutSeptic Pumping Slip - 11 PURITAN AVENUE 3/8/2016 Commonwealth
w City/Town of .
. e
-Record
YS
Form 4
DEP has provided this form far 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. Inform) ti n
I. System Locatio /Rig rout of do , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Righ rout of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name.
Address(if different If p C
Citylrown ' ��'. Stat 'y Zip Code
P r Telephone Number J'
B. Pumping J Record _ ..
(,C)
1, Date of Pumping sate 2. Quantity Pumped: Gallons a
=t
3. Type-of system: ❑ Cesspool(s) eptic 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:
Neil.Batesan F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocafiopAx re contents were disposed:
L S: Lowell Waste Water
�.)
Sign a Haule Date
t5form4.doc-06103 System Pumping Record•Page 1 of 1