HomeMy WebLinkAboutSeptic Pumping Slip - 371 STEVENS STREET 5/17/2016 : Commonwealth of Massachusetts
= Cn/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 houses Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 1
City/Town State Zip Code
2. System Owner. q�
Name
Address(if different from location)
City/Town ' State Zip Code
Telephone Number
3 j `
.B. Pumping JRecord �.
1. Date of Pumping payer' ` r 2 uantity Pumped: Gallons
3. Type-of system. ❑ Cesspool(s) Septic 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. )Loeati where contents-were disposed:
^L5: Lowell Waste Water
Sign a cf Haule Date �'
�-T-
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