HomeMy WebLinkAboutSeptic Pumping Slip - 1650 TURNPIKE STREET 7/13/2016 Commonwealth f Massachusetts
= City/Town of .
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Form 4 � •�F r����i���.�i �
DEP has provided this form for use-by local Boards of Health. Other forms may be'used, but Nle
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. Facill.ty. Information
1. System Location: Left/Right front of house, Left/Right rear 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
y
Cityfrown State Zip Code
2. System owner.
Name*
Address(if different from location)
Cityfrown State Zi !Code
l y-)
Telephone Number
i
13. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank El Tank Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep o If yes, was it cleaned? ❑ Yes ❑ No,
S. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
^L S: Lowell Waste Water
Sign a I Haute Date
t5form4.doc-06103 System Pumping Record•Page 1 of 1