HomeMy WebLinkAboutSeptic Pumping Slip - 209 BRIDGES LANE 9/30/2016 Commonwealth of Massachusetts
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City/Town of . � "
System Pumping-Record
Form 4 �E�`�°1'��,
DEP has provided this form far use.by local Boards of Health. Other farms 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; Left/Right front of house, Left]thl4h�husq Le ft/right side of house, Left Right side of building, Left I Right front of building, uilding, Under deck
Address
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Q� �-. .- C
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dyrrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityl"Town - State��, ,.._.�.., + �Zi��.�ade
Telephone Number !' d
.B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons —`
3. Type-of system: El Cesspool(s) 1018'e/,ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 3� No if yes, was it cleaned? GD-•mss ❑ Na
5. Condition of Syst
,
6r System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lorla tin ' ere contents were disposed:
G S: Lowell Waste Water /
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SignAttle HoulerU Date
06=4.doe•06/03 System Pumping Record•Page 1 of 1
