HomeMy WebLinkAboutSeptic Pumping Slip - 53 WHITE BIRCH LANE 10/15/2008 Coin onwealth of Massachusetts
City/Town ®f \q
System pin cord
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
Important:
When filling out 1. System Location: Left front, left rear, left side of house Right fron right rear, right sid of house.;
farms an the
computer, use
-- ------ ---
only the tab key Address
to move your
cursor-do not City/Town State Zip Code
use the return
key. ._... _. 2. System Owner: LDSI
:_ _. Name -- ---
Address(if different from location)
City/Town State Zip Code
--P 13 _
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: p Cesspool(s) �1-83eptic Tank Tight Tank
Ej Other(describe): — - -----
4. Effluent Tee Filter present. ❑ Yes 0'""No If yes, was it cleaned? Q Yes No
5. Condition of S stem:
I/ )We,,,� � U�_ �.. .....atAt4-e-.-
6. System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc _
Company
7. Location where contents were disposed;_.-,
Q.L.S.D _ _Lowell Wasie Water
igna ure of H u r Date
t5form4.doc 06/03 System Pumping Record-Page 1 of 1