HomeMy WebLinkAboutSeptic Pumping Slip - 370 SUMMER STREET 10/25/2016 Commonwealth of Massachusetts
City/Town of .
System Pumping.Record
Form 4 t
OCIr
DEP has provided this form far use=by local Boards of Health. Other forms may'be'used, butt
Information,must be substantially the same as that provided here. Before using.tl i rmj,6heck with your
local Board of Health to determine the form they use.The System Pumping RecorOAwt;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, Leff/right side of house, 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)
cityfrown ` State Zip Code
fJ•..._
Telephone Number +fir
b d
i
.B. Pumping Record
i
1. Date of Pumping to 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe): �..-
4. Effluent Tee Filter present? ❑ Yes [3-�"No If yes, was it cleaned? ❑ Yes ❑ too,
5. Condition of Syt ter—
6: System Pumped By:
Neil Batesbn F5821
Name Vehicle License Number
Bateson Ehterprises Inc
Company
7. Lo ation where contents were disposed:
C-L S: ') , Lowell Waste Water
I OA-
F
Sign a Haul Date
t5form4.doe}06/03 System Pumping Record page 1 of 1