HomeMy WebLinkAboutSeptic Pumping Slip - 54 VEST WAY 9/1/2016 Commonwealth of Massachusetts
RECEIVED
ED
Y w City/Town of
System Pumping.Record
Form 4 r �4OF�� �� ��i�r;r�f� »c
iU �i�.: �ti[E
DEP has provided this farm for use-by local Boards of Health. Other form's 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 fora+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 front of house, Rig �dfi hs� �` eft,/right side of house, Left/
Right side of building, Left/Right front of build g, Left/Right rear of building, Under deck
Address
� r
City/Town ` State Zip Code
2. System Owner.
Name.
Address(if different from location)
City/Town State Zip Code ;
Telephone Number ` }
JI
r
.B. Pumping Record
1. Date of Pumping bate. ` 2. Quantity Pumped: Gallons —�
3. Type-of system: ❑ Cesspool(s) M-Septic 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.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents-were disposed:
-O^ 5: Lowell Waste Water
B1 ra OA
SignAtife I HaulerU Date
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