HomeMy WebLinkAboutSeptic Pumping Slip - 204 MILL ROAD 5/1/2017Commonwealth of Massachusefts
City/Town of
yste P pi • ecord
Form 4
I' I:
,CFIVE
A nr,cvit.R
uuf vvvv, CAvrCir
DEP has provided this forrn. for use.by local Boards Of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this forrn, 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 Infor atilo
1. System Location: Left / Right front of house, jI Righ ear of hQii a, Left/ right side of house, Left /
Right side of building, Left / Right frOnt of building, Left / Right rear of building, Under deck
Address
frO
City/Town
2. System Owner:
Name
State
Zip Code
Address (if different from location)
Cityfrown
1. Date of Pumping
Type•of system:
Other (describe):
Date
Cesspool(s)
Stat
— t c
Zip Code
Ce-2
Telephone Number
2. Quantity Pumped:
Gallons
eptic Tank 0 Tight Tank
4. Effluent Tee Filter present? 0 Yes If yes, was it cleaned? El Yes Li No,
5. Condition of System:
-et/L(4
6: System Pumped By:
Neil Bates -oh
7.
- Name
Bateson Enterprises Inc
Company
contents were disposed:
Lowell Waste Wate
Pri.-
F5821
Vehicle License Number
Sign e Haute Date
t5forrn4.doc0 06/03 System Pumping Record 0 Page 1 of 1