HomeMy WebLinkAboutSeptic Pumping Slip - 240 GRAY STREET 11/23/2011 Commonwealth of Massachusetts
City/Town of
System u pin Record � �; �w . "l`0 1
Form 4
DEP has provided this form for use by local Boards of Health. Other for .raAs`io-d � `'�
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: Le Ric ht front of hour Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/ ig rf ont of building, Left/Right rear of building, Under deck
Address
City/Town State J Zip Code
2. System Owner: ..
Name
Address(if different from location)
City/Town Y Stat ', ��, �-W ��Z* Co�e ��
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
_..
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? � �
p ❑ Yes [�-'rilo If yes, was it cleaned? E] Yes ❑ No
5. Condition o Sy tem•_
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc
Company
7. Locatio where contents were disposed:
G.L S. Lowell Waste Water
C � .._.
Sign fier e Da#e
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