HomeMy WebLinkAboutSeptic Pumping Slip - 66 COLONIAL AVENUE 7/21/2016 Commonwealth u
IOW of
YS
* tem Pumping- r ' y�
Form 4
DEP has provided this form for use=by local Boards of Health. Other forms may,��
information must be substantially the same as that provided here. Before using.this i �/ h ck 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
I. System Location. Left/ tght front o...._ .,.......,„„�
'� f iia ei, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Lei Right front of building, Left/Right rear of building, Under deck
Address -'
�'�l 'k°d� '4 4m..A `4..; `'...,.,.�,.w✓ ' C.✓ .�d"w yM"""'`w.w ...""w .y��. .,
CWTown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Ci frown '
ty Stat Zi
Telephone Number
. Pumping Record �
A
1. Date of Pumping date 2. Quantity Pumped:
Gallons y
3. Type-of system: ® Cesspool(s) a eptic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ too .. ,. If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6: System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location wi7are contents were disposed:
.L Lowell Waste Water
Sign a Hanle Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1