HomeMy WebLinkAboutSeptic Pumping Slip - 125 COLONIAL AVENUE 12/4/2017 Commonwealth of Massachusetts
CitKown of
System Pumping-Record
Form 4
QTI
DEP has provided this form for use-by local Boards of Health. Other forms may
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. j
A. Facfl!ty. InforMation .
1. System Locatio Left RIg�jt =ront
s , Left/Right rear of house, Left/right side of house, Left f
Right side of buil, Left/Ri building, Left/Right rear of building, Under deck
Address s
Cityrrown State Zip Code
2. System Owner
jj)c
Name'
Address(if different from location)
CityR'own Stat �"� p�+E �
p �
Telephone Number
1
. Pumping record
1. mate of Pumping 2. Quantity Pumped:
Date Gallons ,.
3. Type-of system: E] Cesspool(s) eptic Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? D Yes o if yes, was it cleaned? ❑ Yes ® Na
' 5. Condition of System:
6. System Pumped By:
Neil.Bateson�� � � F5821 t
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
G LS: Lowell Waste Water t
-0- A Ba
f
signgqe I Haule Date
t5form4.doc*06/03 System Pumping Record-Page 1 of 1