HomeMy WebLinkAboutSeptic Pumping Slip - 190 MILL ROAD 6/2/2016 Commonwealth of Massachusefts
a City/Town of
YS
Form 4
DEP has provided this form'for uetby local Boards of Health. Other forms may be'used, but the
information must be substantially the tame 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/Right front of douse, Left/Right rear of house, Left/ lght si e of houses Left/
Right side of building, Left/Right front of building, Left/Right rear of building, nk° �
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State t: � � .� �.�",. Z� Co
de
f
Telephone Number �u
1
Pumping Rpcord
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ ep ❑ No If yes, was it cleaned? es ❑ No,
5. Condition of System,
6: System Pumped By: C
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Lo contents-were diseased:
L _
1 Lowell Waste Water
Sign a cf HaulerU Date
t5form4.doc>06/03 System Pumping Record•Page 9 of 1