HomeMy WebLinkAboutSeptic Pumping Slip - 1024 TURNPIKE STREET 10/13/2016 : Commonwealth of Massachusetts
X
City/ToWn of
RECEIVED
System Pumpiln§,Record
Form 4
I'M4 OF I iIMO,VER
DEP has provided this form for use-by local Boards of Health. Other form's maybe use
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/ t of hou Left I 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 t, To C
City/Town state Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town ' State _ C Z Code
Telepho e)Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons
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 E] No,
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
f '
7, Loca' ere contents were disposed:
G t S. Lowell Waste Water
Sign a Haule Date
0orm4.doe•06/03 System Pumping Record•Page 1 of 1