HomeMy WebLinkAboutSeptic Pumping Slip - 17 LACY STREET 3/17/2016 : 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, Left/Right rear of houseta righ de of house eft/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
. Address
citylrown ' �{— State Zip Code
2. System Owner. P
Name'
Address(if different from location)
City/rown ' Stat Zip Code
Telephone Number
i
i
B. Pumping Record _ r
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of s stem: ❑ Cesspool(s) e tic Tank ❑ Tight Tank `
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes aigo If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
P6 t-V,, �
6.. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location w e contents were disposed:
SG.
Lowell Waste Water
Ar=>
SignAtufe 9t Haule Date
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