HomeMy WebLinkAboutSeptic Pumping Slip - 340 SUMMER STREET 8/2/2016 Commonwealth of Massachusetts '`,V E D;-
City/Town of .
System Pumping-Record
>`t r
Form 4
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
focal 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. Facl ty Information
1. System Location: Left I Right front pf douse, Left I Right rear of house, Le Ight ld of house,` eft I
Right side of building, !refit/Right front of building, Left 1 Right rear of building��lderdecic
Address
citylrown State Zip Code
2. System Owner
Name'
Address(if different from location)
City/Town r $t8 � p pqe
Telephone Number +3.
.B. Pumping Pecord :
1. Date of Pumping pate 2. Quantity Pumped: Gallons '
3. Type-of system: ❑ Cesspool(s) ' Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep ❑ �Id"o If yes,was it cleaned? ❑ Yes ❑ Na
' 5. Condition of'system:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle tricense Number
Bateson Enterprises Inc
Company
T. Locati n here,contents-were disposed:
C L S Lowell Waste Water
Signjt4e HbuieiU Date
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