HomeMy WebLinkAboutSeptic Pumping Slip - 29 SUMMER STREET .. Commonwealth of Massachusetts
City/Town of
System Pumping.Record 6
Form 4
DEP has provided this form for 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
1. System Location; Left/Right front of housLefRig rear of house eft/right side of house, Left/
Right side of building, Left/Right front of building, Left/RlghTrear of building, Under deck
Address
I
L;ny/rown State Zip Code
2. System Owner;
Name'
Address(if different from location)
City/Town State y Zip Co de
Telephone Number +";>
.B. Pumping Record
1 0
1. Date of Pumping Date 2. Quantity Pumped:
Gallons H
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 0 No,
5. Condition of System:
6. System Pumped By:
Neil.Batesan F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
U�gi Lowell Waste Water
4Y-reSA -44�-) -------------
Sign a Hhul Date
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