HomeMy WebLinkAboutSeptic Pumping Slip - 218 LACY STREET 5/24/2016 :�L\ 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 e g n of house Left/Right rear of house, Left/right side of house, Left/
Right side of buil ' , Left/Right ono uildin , Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown Stat de ;
Telephone Number
;
.B. Pumping Kecord
1. Date of Pumping Date 2. Quantity Pumped:
Gallons r
3. Type-of system. ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
6. System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati n-wh re contents-were disposed:
G L S' Lowell Waste Water
C-141 rOA
Signitu.te Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
