HomeMy WebLinkAboutSeptic Pumping Slip - 476 GREAT POND ROAD 8/10/2016 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping.Record AUG 1 5 ?ww�
Form 4
"OWN OF Q.l ,c i,.A ���x rt��wh�
DEP has y i�.�a�i66` e ;��,•E
• s provided this farm far use=b local Boards of Health. ether form`s �ui 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 local Board of Health or other approving authority.
A. Facility, Information
1. System Location: Left/Right frartt of Crouse, Left/Right rear of haul. Left/.fig side of o Left/
Right side of building, Left/Right front of building, Left/Right rear of bui ding, Un
Address r
„w
city/Town State Zip Cade
2. System Owner:
Name'
Address(if different from location)
City/Town State-
Telephone Number
t
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: lo
Gallons
3. Type-of system: ❑ Cesspool(s) ❑ Se tic Tank ❑ Tight Tank
they(describe):
4. Effluent Tee Filter present? ❑ Yap ❑ No If yes,was it cleaned? ❑ Yes ❑ No,
' S. Condition of System:
6. System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lacatia Mere contents-were disposed:
G S: Lowell Waste Water
Sign a cf Hauie Date
t5farm4.doc•06/03 System Pumping Record•Page 1 of 9