HomeMy WebLinkAboutSeptic Pumping Slip - 125 SAW MILL ROAD 8/26/2016 Commonwealth of Massachusetts RECEIVED
City/Town of r
S ' tem P''�; mpin§-ReCOf d TOMq� F'���I��PRI[d n:l�ie���vi:�IR
Form 4 i � ��bJ ii i.,���iIn,te ��� �.:.ti1
DEP has provided this form 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 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: Loft/Right front of house, Left 9 grew hours , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left I Right rear of building, Under deck
Address )
City/`rown State - Zip Code
2. System Owner:
Name•
Address(if different from location)
Citylrown ' State �, ip code ;
Telephone Number r'
'" 1
B. Pumping Record `}..
1. Date of Pumping crate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) aseptic Tank ❑ Tight Tank
❑ Other(describe).
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
6. Condition of System: -V\
Y
6: System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca ' n contents-were disposed:
G U Lowell Waste Water
U VOA
{
Sign a I HaulerU Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1