HomeMy WebLinkAboutSeptic Pumping Slip - 50 JAY ROAD 10/6/2016 Commonwealth of Massachusetts
City/Town of Vi„,µCEIVE
. •
System Pumping-Record O(IJ-
Form 4
bvw T0W4 0'
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
I. System Location: Le l ht front of hour), Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Rig ron building, Left/Right rear of building, tinder deck
. Address �...X-�' .�., .....•� '�..11..., �. ... „�
Cityrrown .! State Zip Code
2. System Owner
Name'
Address(if different from location)
citylrown ' State ` Code
Telephone Number
i
!,r
.B. Pumping Pecord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) (q-~S'eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
J\-
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. La tiort�,6rcontents were disposed:
G L,SjP Lowell Waste Water
Sign a Haute Date
i
i
t5form4.daa-06!48 System Pumping Record•Page 1 of 1