HomeMy WebLinkAboutSeptic Pumping Slip - 32 DEER MEADOW ROAD 10/16/2017Cornmonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
•
DEP has provided this forrn. for use.by local Boards Of Health. OtherTril
F N;:,:"AliwNooVEbRut 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 house, Left
Right side of building, Left / Right frOnt of building,
2. System Owner:
, Left/ right side of house, Left /
Fght rear of building, Under deck
Address (if different from location)
City/Town
State Zip Code
D6'1 °7 Le4")—D-
Telephone Number
•
B. Pumping Record
7
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Typeof system 0 Cesspool(s) E3ieptic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present? 0 Ye.p If yes, was it cleaned? 0 Yes El No,
" 5. Condition of System: /) vt./1/44/ teue
6: System Pumped By:
Neil BatesCp
• Name
Bateson Enterprises Inc
Company
7. Locatio,Jere contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Signtufe q Hauieif 1 Date
5form4.doc• 06/03 System Pumping Record • Page 1 of 1