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bEP.has provided thli form for use by local Boards of Health. The System Pumping Record must
be submitted to the.(ocal'Board of Health or other approving authority,
A Facility tnforrOtion ,
,r hed fllllng out . 1 a
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System Owner-,`
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Address(if different from location)
City/Town tate >
t Telephone Number
!
,. , pumping Record
late of Pumping ` ""aPumped:
ry `�
P g Quantity
Oate 2 ca ons
Typo of,systerrt, Q Cesspools) Tank
S, ptic Tank
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Other(descrlbe)r
4 Effluent
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Filter' resent?.❑ YesNo
r P 1 y as it cleaned? s
If es, w ❑ Ye []'No
5 Cond(�lon of Sys#qm�` r
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http,//www mass goV/dep/water/ipp.rQv4ls/tSforms,htm#inspect
W(orm4.doC+tM/t)3 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts JE
a
µ City/Town of
4 S stem Pumping
Record TWMM,Mw .-,iqwI� i/ l [) Nnf&
Form 4 � � i mi�a�l p. 6ilayi� u„r
DEP has provided this form lor 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 Locatio6 igh rout c►f h�u;Left/Right rear of house, Left/right side of house, Left/
Right side of builil lnft/Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
I
Name
Address(if different from location)
Citpaown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date' p Quantity Pumped: Gallonsc�
3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes /No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatign-where contents were disposed:
G.LS. Lowell Waste Water
Sign toe Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
City/Town of
System Pumping Record S[,q: 3 014
Form 4 i'a::vVo�l U h�40u H u a i/U411)OVEIR
lIEAL INI i u'AR e UO-
DEP has provided this form for use�by local Boards of Health. Other fo'ins may ti96d,V e
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�''.`' lgh rant of house, eft/Right rear of house, Left/right side of house, Left/
Right side of bl�lft/Rig ui ding, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityfrown State ZiCode
TelephoTie Number
B. Pumping Record
1. Date of PumpingDate2. Qu ntity Pumped: - -
DGallons
3. Type of system: ElCesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:/
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ince
Company
7. Loca ' n_ re contents were disposed:
Ca S. Lowell Waste Water
SignAtufe cf Haule Date
t5form4.doc•06/03 System Pumping Record•page 1 of 1