HomeMy WebLinkAboutSeptic Pumping Slip - 35 TIFFANY LANE 10/4/2016 Commonwealth of Massachusetts
City/Town of
System Pumping.Record
Form 4
DEP has provided this form far use=by local Boards of Health. Other forms 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.
I. System Location: Left/Right front of house, Left/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
Citylrown °°y State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown ' State Zi e
Telephone Number "3
.B. Pumping Record
1. date of Pumping 2. Quantity Pumped: --
Date Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 21N_0 if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Sys ern: r
6. System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loictan!
L S'. tae contents-were disposed:
Lowell Waste Water
[YfaA
SigJtu to cf HaulerU Date
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