HomeMy WebLinkAboutSeptic Pumping Slip - 39 PADDOCK 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 #frli� ont ofdouse, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Rlg, t—of-Guildirig, Left/Right rear of building, Under deck
• Address
City/Town State Zip Code
2. System Owner.
C •
Name
Address(if different from location)
City/Town state Code
t
Telephone Number -"
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons Y
3. Type-of s
yp y.stem:
❑ Cesspool(s) eptic Tank El 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 Bates-on ' F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
G L �`' Lowell Waste Water
Sign a Haule Date
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