HomeMy WebLinkAboutSeptic Pumping Slip - 173 BRIDGES LANE 8/3/2016 : Commonwealth of Massachusetts [" ,71rc-.NMCI
= City/Town of
System Pumping-Record -
Form 4
n�
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
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the total Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left/ rght fron#of house Left 1 Right rear of house, Left 1 right side of house, Left I
Right side of building, Le Rigf� ron o uildirig, Left 1 Right rear of building, Under deck
Address j Ar
Citylrown state zip Code
2. System Owner.
Name•
Address(if different from location)
Cityfrown ' - Stat de •
f Telephone Number
.B. Pumping kocord
1. Date of Pumping Date 2• Quanti Pumped: Gallons
3. Type•of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ® o If yes, was it cleaned? ❑ Yes ❑ No
" 5. Condition of.System:
6. System Pumped By:
Neil.Meson • F5821
Name Vehicle Ucense Number
Bateson Enterprises Inc•
Company
7. Location ere contentsrwere disposed:
rL S. Lowell Waste Water
F
Sign a Hi3ule Date
t5form4.doc•06103 System Pumping Record•page 7 of 4