HomeMy WebLinkAboutSeptic Pumping Slip - 125 BRIDGES LANE 9/27/2016 Common wealth of Massachusetts
City/Town of
System Plumping.Record
Form 4
DEP has provided this farm far use.by local Boards of Health. Other forms may *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
I. System Location: Left/Right front of house, Left I Right rear of house d'i rig side of how, eft I
Right side of building, Left/Right front of building, Left/Right rear of ding, Under`d OE
Address�—,,~
City/Town State Zip Code
2. System Owner:
Name`
Address(if different from location)
City/Town ` Stater��� Zip Code
Telephone Number
t
B. Pumping Record
1. Date of Pumping Date • Quantity Pumped:
Gallons r
3. Type-of system: ❑ Cesspool(s) ❑Tank ❑ Tight Tank r
❑ tither(describe):
4. Effluent Tee Filter present? ❑ Yes 0°1bw..... If yes, was it cleaned? ❑ Yes r-1 No,
' S. Condition of Syste .
6. System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Loca' v re contents were disposed:
_L S: Lowell Waste Water
Sign a Houle Date f
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