HomeMy WebLinkAboutSeptic Pumping Slip - 93 CRICKET LANE 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
1. System Locatio Rig rori of house Left/Right rear of house, Left/right side of house, Left/
Right side of bul g, Left/ Ig t ront of building, Left/Right rear of building, Under deck
Address
CWrown 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 Date 2. Quantity Pumped: Gallons i
3. Type-of.s stem: ❑ Cess p ool(s) 0-S e p tc Tank Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 64es ❑ No If yes, was it cleaned? es ❑ No,
5. Condition of System:
6: System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locatio were contents were disposed:
L S: Lowell Waste Water
Signitufe 9t Haul Date
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