HomeMy WebLinkAboutSeptic Pumping Slip - 1 GRAY STREET 12/4/2017 Commonwealth 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 house, Le Rlght rear o--bbdse, Left/right side of house, Left/
Right side of building, Left/Right front of building, Le fight rear of building, Under deck
Address
Cityfrown state Zip Code
2. System Owner:
Name
Address(if different from location)
City/1 own state CEO f Zi ;
Telephone Number '
I
B. Pumping Record �-
1. Date of Pumping 2. Quantity Pumped:
Date Gallons ,>
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ElYes 2-h-o If yes, was it cleaned? ❑ Yes ❑ No,
5. Conditio -of System:
-- =
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc 9 ?013
Company
7. �aLLAP�l
ca' .
er ontents were disposed:
Lowell Waste Water
W- a 0A. B 0�
-SIqnkufe 9t Haule Date
t5form4.doc•06/03 system Pumping Record•Page 1 of 1
Commoanwalth of Massachusetts
, Massachusetts
Svstem Pumnina Record
System Owner System Location
Date of Pumping: "" Quantity Pumped:'*�-,��Z",� gallons
Cesspool: No Yes [] Septic Tank: No Yes
System Pumped by: Va&d4w 454&vft4W License#
Contents transferred to: Great-or Lawrence ftnjtary District
Date: Inspector: