HomeMy WebLinkAboutSeptic Pumping Slip - 42 VEST WAY 12/11/2017 Commonwealth of Massachusetts
Per
UtylTown of .
System Pumping.Record
Foran 4
DEP hasprovided 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 bas ubmitted to
the local Board of Health or other approving authority.
A. Facility, lnforiiation
1. System Location: Le iht fr�ofhoys , Left I Right rear of house, Left/right side of house, Left I
Right side of building, Left/Right front of building, Left 1 Right rear of building, Under deck
Address
Citymowa V State Zip code
2. System Owner.
Uj
Name'
Address(if different from location)
CO/Town State ,3 `� rZ!Rode
j Telephone Number ` r .Y
3 [ `
.B. Pumping Record
1. Date of PumpingDate 2. Quantity Pumped: canons
3. Type,of system: ® Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present'? ❑ Yes ®'No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
00� -
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle license Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
.L S: Lowell Waste Water
Sj nAture I Hgulev Date F
t5form4.doa-06/03 System Pumping Record•Page 9 of 1