HomeMy WebLinkAboutSeptic Pumping Slip - 33 SULLIVAN STREET 5/17/2016 : 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
I. System Location: eft? Ightlfjonf oof hou , Left]Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address S3 U� U �— P C�,(4
City[Town State Zip Code
2. System Owner.
DC® v\�
Name'
Address(if different from location)
City/Town State i Code ;
Telephone Number 1
t
.13. Pumping Record
1. Date of Pumping te 2. Quantity Pumped:
Date Gallons ;
3. Type-of system. ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' w e e contents-were disposed:
G L S: Lowell Waste Wafer
1--WOA. * ' . 5_� 6 ----C
Sign a Haule Date
t5form4.dov 06/03 System Pumping Record•Page 1 of 1