HomeMy WebLinkAboutSeptic Pumping Slip - 66 CEDAR LANE 10/17/2016 .. Commonwealth of Massachusetts
Ci /Town o€ .
4
System Pumping.Record
Form 4
y
DEP has provided this form for use-by focal 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 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/Right front of house, Left/Right rear of house ft.,pright e'o houses Left/
Right side of building, Left/Right front of building, left/Right rear of building, Under deck
Address
City/Town state Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town State ZCode
, rte. ,
Telephone Number
B. p'ing kecord ?
1. Date of Pumping sate 2. Quantity Pumped: Gallons
3. Type•of.system. ❑ Cesspool(s) Q eptic nk ❑ Tight Tank ,.
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ o If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of Syste /
l V\,— L
6: System Pumped By:
Nell.Bateson ' P5$21
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location h contents-were disposed:
Lowell Waste Water
Sign a I Haule Date
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