HomeMy WebLinkAboutSeptic Pumping Slip - 29 NORTH CROSS ROAD 6/28/2017Cornmonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
EeEIVED
yL 0 5 n11
of NogT"
-to DEppa
•
DEP has provided this form for useby local Boards Of Health. Other forms may be 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 forrn they use. The ystem 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 side of building, Left / Right front of building, Left
Address
(D-
City/Town
2. System Owner:
r of housoikeft / right side of house, Left /
t rear of building, Under deck
State
Zip Code
Name"
Address (if different from location)
City/Town
State r'N
CL4°9 Z
ipode
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type -of system': El Cesspool(s) Septic Tank El Tight Tank
El Other (describe):
4. Effluent Tee Filter present? C] Ye. E14o
. Condition of System:
If yes, was it cleaned? 0 Yes 0 No,
6: System Pumped By:
Neil. Bateson
• Name
Bateson Enterprises Inc.
Company
7. Locaijpnhere contents were disposed:
Lowell Waste Water
Signtufe qt Haul
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1