HomeMy WebLinkAboutSeptic Pumping Slip - 62 BANNAN DRIVE 10/27/2016 Commonwealth of Massachusetts
City/Town of .
System Pumping.Record
W,
w.
Form 4
CF
DEP has provided this form for use=by local Boards of Health. other forms may=rm ur
information-must be substantially the same as that provided here. Before using.
local Board of Health to determine the form they use.The System Pumping Record must be R4200to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left f Right front of house, Left I Right rear of house, Left./ri ii st` -!R of hou , Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
cay/rown State Zip Cone
2. System owner:
Name'
Address(if different from location)
CityRown State
ti "telephone Number �+ a
i
.B. Pumping tZecord
Ic-J'
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system. ❑ Cesspool(s) optic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes DIN-0--,
If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of Syst m•. '
/ �.`� lam. 4e
6.� System Pumped By:
Nell.Bateson F5821
j Name Vehicle license Number
Bateson Enterprises Inc
Company
7. Locatio9,vk7e a contents were disposed:
f G L S: Lowell Waste Water
Sign a Haule Date
t5formCdoc-06/03 System Pumping Record•Page 1 of 1