HomeMy WebLinkAboutSeptic Pumping Slip - 217 GRAY STREET 10/20/2016 . Commonwealth of Massachusetts
City/Town of
System Pumping-Record
Form 4 �1�:��f.��al�, 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 foram they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Locati rl"IC6_IR-fight rant cif F ous s Left/Right rear of house, Left/right side of house, Left/
Right side of bu'llding—, Left/Righf1'r`6ht of building, Left/Right rear of building, Under deck
Address r� /" ,
city/Town State Zip Coale
2; System Owner. `
Name'
Address(if different from location)
Ci /'town - Code
ty State- ,
Telephone Number �+
1
B. Pumping Record
1. Date of Pumping bate Z Quantity Pumped: Gallons
3. Type,of system: F1 Cesspool(s) peptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? "
p ❑ Yes ❑ No If yes, was it cleaned? es ❑ Na,
5. Condition of System:
6: System Pumped By:
Neil Meson - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. LocatioVere contents were disposed:
G_ Lowell Waste Water
Sign Date
0arm4.doc•06/03 System Pumping Record•Page 1 of 1