HomeMy WebLinkAboutSeptic Pumping Slip - 55 STONECLEAVE ROAD 8/9/2016 Commonwealth of Massachusetts REC.EIVED
City/Town of AUG 15 201 N
System Pumping.record : s l4 a l OVER
Form 4 HEALTH����:KA �1��.��
DEP has provided this form for useaby 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 Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
I. System Location: Left , fight front of houses'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
city/rown state zip code
2. System Owner. ,
Name
Address of different from location)
City/Town State �, Zip code
Telephone Number
.13. Pumping Record
1. Date of Pumping �- 2. Quanti Pumped:
• Date Gallons =
3. Type-of system: ❑ Cesspool(s) ❑-. eptic Tank ❑ Tight Tank
❑ Other(describe): �'�
4. Effluent Tee Filter present? ❑ Yes �-iVo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. L"t'lo! #r_contents-were disposed:
G S: Lowell Waste Water
Sign a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1