HomeMy WebLinkAboutSeptic Pumping Slip - 129 CHRISTIAN WAY 5/1/2017Commonwealth of Massachusetts
City/Town of
yte mplin ecord
4
!MA
• I r ), I
DEP has provided this form for usetw local Boards Of Health. Other forMS may Dewed, but the
information must be substantially the same as that provided here. Before using.this form, check your
with
local Board of Health to determine the forM they use. The System Pumping Record must be subwmiitte-clotor
the local Board of Health or other approving authority.
• A. Facility I formaflon
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
2. System Owner:
Address (if different from location)
City/Town
Telephone Number
81
I. Date of Pumping
!cord
Date
2. Quantity Pumped:
Gallons
Type of system 0 Cesspool(s) •9- eptic Tank E] Tight Tank
Other (describe):
4. Effluent Tee Filter present? L e 0 No If yes, was it cleaned? EI—linicrY No,
Condition of Sys
6: System Pumped By:
Neil Bateson
• Name
Bateson Enterprises Inc.
Company
7. Location where contents were disposed:
Lowell Waste Wat
Sign e. H ule
F5821
Vehicle License Number
Date
t5form4.doc• 06/03
System Pumping Record Page 1 of 1