HomeMy WebLinkAboutSeptic Pumping Slip - 66 JAY ROAD 8/19/2016 RECEIVED
.�C_, Commonwealth of Massachusetts
City/Town of .
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System Pumping-Record IE lw u a i:_i 1AFZTM04
Form 4
y
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 local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left/ i ht fr nt of a ; Left I Right rear of house, Left/right side of house, Left/
Right side of building, Left I Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town ' State Zi p Code ;
3 ; _if
Telephone dumber
d<;
.B. Plumping Record ,.
1. Date of Pumping safe 2. Quantity Pumped: :
Gallons —`
3. Type-of system: ❑ Cesspool(s) Q eptic Tank ❑ Tight Tank
❑ Other(describe):
4, Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
6. System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location •here contents were disposed:
Lowell Waste Water
_5gnAtu a llaule Date
t5form4.doc.-06/03 System Pumping Record•Page 1 of 9