HomeMy WebLinkAboutSeptic Pumping Slip - 35 SHANNON LANE 4/22/2016 : Commonwealth .of Massachusetts
_ Clty/Town of .
System Pumping-Record
Form 4
bE*P has.provided this form for use-by local Boards of Health. Other form's 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/Right front of house, Left rght rear o�hfious eft/right side of house, Left Right side of building, Left/Right front of building, Le ig lding, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityrrown ' State-j Zip Code
Telephone Number
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. Condition of bysterrj: `�
6. System Pumped By:
Neil.Meson - F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
G. S: Lowell Waste Water
Sign a I Haul Date
0orm4.doc•06103 System Pumping Record•Page 1 of 1