HomeMy WebLinkAboutSeptic Pumping Slip - 21 ASH STREET 5/23/2016 : 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 hour , ee /Righ ear ff house-,left/right side of house, Left/
Right side of building, Left/Right front of biding, Left/R-igMearrof building, Under deck
Address
Citymown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town Stater Zip Code
y o
Telephone Number
i
.B. Pumping JRpcord
1. Date of Pumping Date P`� ��2, a n tity Pumped: S'O
Gallons t
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:
-Ain OLki� -et J-C
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents were disposed:
Lowell Waste Water
SignAtu a 4 HaulelJ Date
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