HomeMy WebLinkAboutSeptic Pumping Slip - 194 GRAY STREET 9/12/2016 Commonwealth of Massachusetts
Y City/Town of .
System Pumping.Record
Form 4 � j �qj,���� ���������
DEP has provided this farm for use-by local Boards of Health. Other forms may be bled, 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 forrh 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, Left I 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 ""� .. LCA-,
Cityrrown (� State Zip Code
2. System Owner.
Name'
Address(if different from location)
city/T'own ` State Zip Code ;
Telephone Number
i
.B. Pumping Kecord
1. Date of Pumping bate 2. Quantity Pumped:
Lallans
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o if yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:7�
6. System Pumped By:
Nell.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatio contents-were disposed:
G�S. Lowell Waste Water
Signgqe qt Houle Date
06=4.doo-06/08 System Pumping Record•Page t of 1