HomeMy WebLinkAboutSeptic Pumping Slip - 45 SHANNON LANE 6/12/2010 IL'\ Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
�N
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 tQ determine the form they use. The System Pumping Record must be submitted to "I
the local Board of Health or°other approving authority.
A. Facility Information
1. System Location: Left side of house, Right side of house, Left front of hou e, Right front of house,
Left rear of house, Right rear of house. Left rear of building. Right rear of but
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State ®0 Z` Code
Telephone Number `7
B. Pumping Record _
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 No If yes, was it cleaned? ❑ Yes ❑ No
5. Cond'tion of System-
FA-Acla UkA � LA
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location wbere contents were disposed:
L_S.D Lowell VVaste ter
Signature of u14( Date T
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