HomeMy WebLinkAboutSeptic Pumping Slip - 100 SAW MILL ROAD 12/13/2016 : Commonwealth of Massachusetts
City/Town of
u ,
S* tem Pumping-Record
Form 4
J'¢'W° ,4 0. u',LYB O H ANOUVi°iR
DEP has provided this form for use-by local Boards of Health. Other forms may a uuser ;151111 u#is
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/T�Jht , Left!right side of house, Left/
Right side of building, Left/Right front of building, ebuilding, Under d eck
Address
Ci-y town State Zip Code
2. System Owner.
Name*
Address(if different from location)
City/Town ' State J `7 �P d
t Telephone Number
.B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) E is Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep o If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
6.• System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7, Location hiere.contents-were disposed:
Lowell Waste Water
w
IT rOA
Sign a I HauleV Date
t6form4.dow 06/03 System Pumping Record*Page 1 of 1
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