HomeMy WebLinkAboutSeptic Pumping Slip - 180 MILL ROAD 6/6/2017Commonwealth of Massac
V\I
City/Town of .
System Pumping- Record
Form 4
DEP has provided this form for usern local Boards Of Health. Other, fonlp rnpOe Lied, --hut the: r
information must be substantially the same as that provided here.'BefOre Lising.this fenti, Check W th your
local Board of Health to determine the form they use. The ystern Pumping Record must be submitted to
the local Board of Health or other approving authority.
•
JUN 0 9 2017
• A. Facility. Information
1. System Location: Left / Right front of house, Left
Right side of building, Left / Right front of building,
Addr
City/Town
2. System Owner
ear of , Left/ II ht side of house, Left /
/ Right rear of building, Under deck
Narrle.
Address (if differentfrom tocation)
City/Town '
•
Telephone Number
B. Pumping Record
1. Date of Pumping
Date
2. Quanti Pumped:
Gallons
3. Type.of system 0 Cesspool(s) ESptic Tank D Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes
" 5. Condition of System:
6: System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S.
Sign
Lowell Waste Water
If yes, was it cleaned? 0 Yes El No,
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1