HomeMy WebLinkAboutSeptic Pumping Slip - 11 BARCO 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. Inform' ation
1. System Location: Left/Right front of house, Rig rear of hous , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Ctty/Town State Zip Code
2. System Owner.
V\1
Name
Address(if different from location)
Citylrown State ip de.�
F
- �t_(-
Telephone Number
.B. Pumping Record
_D �
1. Date of Pumping Date 2. Quantity Pumped: Gallons y
3. Type-of system: ❑ Cesspool(s) epi is Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lora' I'te contents-were disposed:
GLS'-Q Lowell Waste Water
Sjgnjqe I Haulejj Date
0orm4.doc•06/03 System Pumping Record•Page 1 of 1