HomeMy WebLinkAboutSeptic Pumping Slip - 208 OLD CART WAY 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: Left/Right front of house, Left/Right rear of house, Left right side of hour 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.
�(7
Name'
Address(if different from location)
city/Town State Zip Code
Telephone Number
J;•
.B. Pumping Record
1. Date of Pumping Quantity Pumped: Gallons
Y
Date
3. Type-of system: F-1 Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
V v
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Logggfion where contents-were disposed:
G L S Lowell Waste Water
Sign a Hauls Date
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