HomeMy WebLinkAboutSeptic Pumping Slip - 495 REA STREET 7/31/2017Commonwealth of Massachusetts
City/Town of . -
System Pumping. Record
Form 4
DEP has provided this form 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 form, 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 hous L igh ar of hous) Left / right side of house, Left /
Right side of building, Left / Right front of b tang, Left / Right rear of building, Under deck
Address
City/Town
Lie.S � e k)c. kL A\A).‹.Aj9,S-
State Zip Code
2. System Owner.
Name
Address (if different from Location)
City/Town State
—cwPCade
Tetephone Number
1.1
B. Pumping Record
1. Date of Pumping
3. Type, of system: ❑
❑ Other (describe):
Date
2. Quantity Pumped:
Gallons
Cesspool(s) p Lc Tank ❑ Tight Tank
4. Effluent Tee Filter present? 0 Yes L — N S If yes, was it cleaned? ❑ Yes ❑ No,
" 5. Condition of System
6; System Pumped By:
Neil. Bateson
' Name
Bateson Enterprises Inc
Company
7. Location e - contents•were disposed:
Lowell Waste Water
Sign e • Hau
F5821
Vehicle License Number
Date
15form4.doc• 06/03 System Pumping Record • Page 1 of 1