HomeMy WebLinkAboutSeptic Pumping Slip - 295 REA STREET 10/27/2016 Commonwealth of Massachusetts
r r City/Town of .
Systems Pumping Record RECEIVED
Form 4
DEP has provided this forme for use�by local Boards of Health. Other forms may ' h
information'must be substantially the same as that provided here. Before using.tq your
local Board of Health to determine the form they use.The System Pumping Record mus e s itted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left/Right front of house, Left J Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, tinder deck
. Address r _. f,,
CWTown State Zip Code
2. System Owner: �[
Name
Address(if different from location)
Cityrown Statere-N %do
Telephone Number
.B. Pumping Record
1. Date of Pumping bats 2. Quantity Pumped: Gallons �
3. Type-of system. ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? s ❑ No,
5. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents were disposed:
Lowell Waste Water
2
Sign a Haule Date
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