HomeMy WebLinkAboutSeptic Pumping Slip - 35 SHANNON 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 Location: Left/Right front of house, Left t rear of h Qb, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address _
CWrown state Zip Code
2. System Owner.
Lao 0`a 1►
Name
Address(if different from location)
City/Town State Zip Coop
Telephone Number
r
i
B. Pumping Record �.
1. Date of Pumping 2. Quantity Pumped:
Date 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 Syste
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
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LS. Lowell Waste Water j
Lt
SigWHawul Date
WU
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