HomeMy WebLinkAboutSeptic Pumping Slip - 149 BRIDGES LANE 9/30/2016 Commonwealth of Massachusetts r
r ,o,
CIty/Town of C
System Pumping.Record
,�.. Form 4
DE•P has provided this farm for use-by local Boards of Health. Other forms may ybe•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 Aiight rya 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
City/frown state Zip Code
2. System Owner.
Name`
Address(if different from location)
citylrown State i Zip code
Telephone Number t
.B, Pumping Record , `.
1. Date of Pumping Date 2. Quantity Pumped: Gallons r
3, Type-of system. ❑ cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6,• System Pumped By:
Nell.Batesbn - F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7, Location here contents were disposed:
G L S:�') Lowell Waste Water
s
Sign a cf HbuleV Date
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