HomeMy WebLinkAboutSeptic Pumping Slip - 495 REA STREET 7/13/2016 Commonwealth of Massachusetts
i W f . o
YS
Pumping. Record
Form 4
DEP has provided this form for use=by local Boards of Health. Other forms may be'used, b'u 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 Mouse, a igh a of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ` r �.�"""
Citylrown State Zip Code
2. System Owner: '
Name'
Address(if different from location)
City/Town State. Zip Code
i. �
Telephone Number
Pumping poor �
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
—T
3. Type-of system*yp y ® Cesspool(s) - 3 eptic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ® No,
5. Condition of Sy Ve
/L a _..
6. System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo 'on ere contents were disposed:
L S'. Lowell Waste Water
Sign a —Haulelj Date
t5form4.doc•06/03 System Pumping Record.Page 9 of 1