HomeMy WebLinkAboutSeptic Pumping Slip - 21 EASY 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
1. System Location: Left ' �Rron ou , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left of building, Left/Right rear of building, Under deck
• Address
CWTown State - Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town Stat7_ic Code
Telephone Number
r
.B. Pumping JRecord �
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
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 st m: C
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Lo o"here contents-were disposed:
G,_ S. � Lowell Waste Water
Sign a Haule Date
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