HomeMy WebLinkAboutSeptic Pumping Slip - 45 CRICKET LANE 4/11/2016 Commonwealth of Massachusetts
City/Town of
S ' tem Pumping.Record Mf
YS
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 tame 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 r of hots, Left right side of house, Left
Right side of building, Left Right front of building, Left Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner: o's
Name'
Address(if different from location)
cityrrown State /;'dry 11 1p(;jode-
0
Telephone Number
B. Pqmping Rpcord
1. Date of Pumping
Date 2. Quantity Pumped: Gallons
3. Type-of,system. ❑ Cesspool(s) 11_6e'Pfic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep [D--No If yes, was it cleaned? ❑ Yes ❑ No
6. Condition of System:
6.. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location," re contents were disposed:
/L G L S Lowell Waste Water
qSignn e Haule Date
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