HomeMy WebLinkAboutSeptic Pumping Slip - 138 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
1. System Location: Left/Right front of house, Left/Rfijt rear of hoes Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address C � � — �
Cityrrown State Zip Code
2. System Owner. I �
Name
Address(if different from location)
City/Town State/7_� � � Zip�de '
j Telephone Number +`v
.B. Pumping tlecord
1. Date of Pumping Date 2. Qua tity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
" 5. Condition of System: r�� �����t../� � � •
4 �
6: System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locatio contents were disposed:
,.L Q Lowell Waste Water
SignAtLfe qt Haul Date f
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