HomeMy WebLinkAboutSeptic Pumping Slip - 83 LIBERTY STREET 10/17/2016 Commonwealth of Massachusetts
City/Town of
n.
System Pumping-Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe bsed, 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: Left/Righ front ref hour Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Rig ton o building, Left]Right rear of building, Under deck
Address
CWTown State Zip Code Ij
2. System Owner.
Name
Address(if different from location)
Citylrown ' State, ZiICCode
"telephone Number
i
.B. Pumping Record /
(
1. Date of Pumping date 2. Quantity Pumped: Canons
3. Type-of.system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent flee Filter present? ❑ Yep if yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of s em: !.
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc`
Company
7. Locations where contents-were disposed:
-
G L Lowell Waste Water
Sign a Haul Date f
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