HomeMy WebLinkAboutSeptic Pumping Slip - 137 CHRISTIAN WAY 10/19/2016 Commonwealth of Massachusetts
_ City/Town of . F
Sy' tern Pumping-Record
Form 4
DEP has provided this form far use.by local Boards of Health. Other form's may ba'usa'8,"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 a "Agh%r6 f house Left/Right rear of house, Left/right side of house, Left f
Right side of bull Left/ n o buildin Left/Ri ht rear of buildin Under deck
9 gy 9� g 9�
Address a
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town Stat r `r � Zip Code
Telephone Number
.B. Pgmping Record
b
1. Date of Pumping sate 2. Quantity Pumped: -t
Gallons L
3. Type-of s stem:
yp y. El cesspool(s) eptic Tank ® Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ®-Nb If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System:
6; System Pumped By:
Nell.Bateson " F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents-were disposed:
: S Lowell Waste Water
(fl/ 0A. Bz6z-4���
Sign a I Haule Date
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