HomeMy WebLinkAboutSeptic Pumping Slip - 15 COLONIAL AVENUE 8/23/2017 Commonwealth of Massachusetts
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S .stem Pumping.Record � �
Form 4
DEP has provided this form for use-by local Boards of Health. Cather forms may be'vsf the
Information,roust 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 1
the local.Board of Health or other approving authority.
A. Facility. Infor�inatlonl -
1. System LocatiaY Rig an of house', Left/Right rear of house, Left/right side of house, Left
Right side of 6w log, Left/Rig r 6f" uildirig, Left/Right rear of building, Under deck
Address ����,..-•.W— ��,,� +�...��`�L� '.�� E" �.��
citylrown State Zip Code
2. System Owner.
t
Name' J
t
Address(if different from location)
City/Town stab �( 7- Z
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Telephone Number
F.
B. Pumping Record
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1, Cate of Pumpingcrate 2. Quantity Pumped:
Gallons
3. Type-of s stem:
yp y. ❑ Cesspaol(s) eptic Tank El Tight Tank
❑ Other(describe):
4.. Effluent Tee Filter present? [] Yes &No If yes, was it cleaned? ❑- Yes ❑ No, j
j
' 5. Condition of stem:
6.- System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
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7. Location whgrs contents-were disposed:
S
Lowell Waste Wafer
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Sign a HbulerU Date
Mormkdoc•06/03 System Pumping Record•Page 1 of 1
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