HomeMy WebLinkAboutSeptic Pumping Slip - 268 REA STREET 4/5/2016 Commonwealth of Massachusetts
_ City/Town of
System Pumping r �. 4
Form 4� I t ` tt
HEALTH MOAR-WENT
DEP has provided this form for use by local Boards of Health. Other forms ma MM ut 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 side of house,. Right side of house, Left front of house, Right front of house,
Left rear of h�/ �.ouse, RI h rear of house._ :1eft rear of building. Right rear of building.
y )
Address
w
s ,. _
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping ( 6 2. Quantity Pumped:
Date Gallons
1 Type of system: ❑ Cesspool(s) 19/septic Tank ❑ Tight Tank
❑ Other(describe): —
4. Effluent Tee Filter present? ❑ Yes [�/No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ,i�� vac,Gay
4
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L D Lowell Waste Water
g to a of Haul r Date
t5form4.doc•06/03 System Pumping Record-Page 1 of 1
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 hou , Left/right side of house, Left/
Right side of building, Left/Right front of building, Le ig rear of building, Under deck
Address `� � st-
City/Town State Zip Code
2. System Owner:
L-1--A
Name
Address(if different from location)
City/Town State de
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 present? es ❑ No 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. 7aLLS-0 i where contents were disposed:
Lowel l Waste Water
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1