HomeMy WebLinkAboutSeptic Pumping Slip - 153 MILL ROAD 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
I. System Location; Left/Right front of house, Left/Right rear of house, Left/ ' ht'side ofafhou
house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Un er ec
Address
City/Town State Zip Code
2. System Owner._
Name'`
Address(if different from location)
city/Town ' State Zip Code
Telephone Number
e j
.B. Pumping Record �
1. Date of Pumping ( Quantity Pumped: '
Date Gallons y
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:
L�
6: System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
.L S: Lowell Waste Water
Sign a Haule Date
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