HomeMy WebLinkAboutSeptic Pumping Slip - 80 LOST POND LANE 7/31/2017Cornmonwealth of Massachusetts
Citij/T'own of .
System Pumping Record
14 14400\IER
Form 4 100 of 14,0iFtlok-RAEsT
. • voLiti D'-' —
DEP has provided this form. for use.by focal Boards Of Health. Other forms may be used, but the
informationmust 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, Information
1. System Location: Left / Right front of house, Left / se, Left / right side of house, Left /
Right side of building, Left / Right frOnt of buildirig, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
0
State
Zip Code
Warne
Addre
(if diffe
nt fro
location)
City/Town '
State.
Telephone Number
B. Pumping Record
(17
1. Date of Pumping Date 2. Quanti Pumped:
3. Type•of system': 0 Cesspool(s) eptic Tank 0 Tight Tank
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. LocohereP0ntefltSWere disposed:
Lowell Waste Water
Sign
Gallons
If yes, was it cleaned? 0 Yes 0 No,
F5821
Vehicle License Number
Date
t5form4.doc• OS/OS System Pumping Record • Page 1 of 1