HomeMy WebLinkAboutSeptic Pumping Slip - 133 COLONIAL AVENUE 10/14/2016 . ,, Commonwealth of Massachusetts
_ City/Town of .
System Pumping.Record
Form 4 r>"
DEP has provided this farm 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 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 douse, Left ��rearof- ; Left/right side of house, Left/
Right side of building, Left/Right front of building, building, Under deck
Address
,M
City/Town State Zip Code
2. System Owner.
cw__�
Name'
Address(if different from location)
Cityrrown State o Zi
Telephone Number f
a r
i
f
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons �
3. Type-of system: ❑ Cesspool(s) p ank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6: System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents were disposed:
G,v S. Lowell Waste Water
Sign a Houle Date F
t5form4.doc-06/03 System Pumping Record-Page 1 of 1