HomeMy WebLinkAboutSeptic Pumping Slip - 130 CHRISTIAN WAY 10/12/2016 Commonwealth of Massachusetts
x City/Town of FRECEIVED
w° System Pumping.Record
Form 4
1,Cpvv j Or
DEP has provided this form'for use-by local Boards of Health. Other formilMiy`6 tV e ,�ut 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 I 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 t. _ev
Citir own State _ -- Zip Code
2. System Owner.
Name'
Address(if different from location)
cityfrown State ._Zip Code
?
Telephone Number
i
i
.B. Pumping record :
1. Date of Pumping sate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptle Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 090---'
If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
C�
6; System Pumped By:
Nell.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location w_he, contents-were disposed:
ALS-Q Lowell Waste Water
. 4,1L
signAtu I Te 4 HauleV Date
06=4.doe-06/03 System Pumping Record•Page 1 of 1