HomeMy WebLinkAboutSeptic Pumping Slip - 36 HAWKINS LANE 11/9/2016 Commonwealth of Massachusetts RECEIVED
4 City/Town of .
System Pumping.Record O
Form 4
DEP has provided this farm for use=by local Boards of Health. Other forms may ybe 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, Left/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
Telephone Number
.B. Pumping Pecord
1. Date of Pumping Date 2. Quantity Pumped: ----
Gallons
3. Type-of system`: ❑ Cesspool(s) ❑ ep cticti Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0_4� If yes, was it cleaned? ❑ Yes r_1 No,
5. Condition of m•
6. System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lo Lion- here contents were disposed:
G�-S. Lowell Waste Water
�•.,----� to�C
Sign a Hanle Date {
t5form4.doc*06103 System Pumping Record•Page 1 of 1
