HomeMy WebLinkAboutSeptic Pumping Slip - 20 COLONIAL AVENUE 7/31/2017Commonwealth of Massachusetts
.City/Town of .
System Pumping- Record
Form4
DEP has provided this form for useeby local Boards of Health. Other forms may be 'used, but the
information' must be substantially the same as that provided here. Before using .this forrn, check with your
Iocai 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 ti Righ rout of hrot Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear cif building, Under deck
Address
City/Town
e
2. System Owner.
Name"
Yrarkc�
State Zip Code
Address (if different from location)
City/Town
State' Zip Code
Lis - (err ce7
Telephone Number
B• Pumping Record
1. Date of Pumping
Date
n . Quantity Pumped:
Septic
3. Type -of system: 0 Cesspool(s) Tank ❑ Tight Tank
❑ Other (describe):
�. Effluent Tee Filter present? ❑ Yes
" 5. Condition of System: n l
6: System Pumped By:
Neil. Bateson •
Name
Bateson Enterprises Inc'
If yes, was it cleaned? ❑ Yes ❑ No,
al 1,,kj
Company
7. Locatl'or�where contents -were disposed:
Lowell Waste Water
Sign = e • Hauler
F5821
Vehicle License Number
Date
tSfarm4.doc• 06103 System Pumping Record • Page 1 of 1