HomeMy WebLinkAboutSeptic Pumping Slip - 173 BRIDGES LANE 12/5/2017 Commonwealth of Massachusef#s
W UWTown of .
M1 T
Q System Pumping-Record
Form 4
p
DEP has provided this form for use-by local Boards of Health. other forms maybe 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, z
1. System Location: Left/ �Rigrtt'r'o'fn
Left/Right:rear of house, Left/right side of house, Left I
Right side of building, Leldirig, Left/Right rear of building, Under deck
Address
c 7 - YA L �
Cityrrown state Zip Code
2. System Owner.
Name'
Address(if different from tacation)
City/Town Stat _ Zip Code
�(
f Telephone Number
a
.B. Pumping Record
1. Date of PumpingDate 2. Quantity Pumped:
Gailans t�T
3. Type-of system: ® Cesspool(s) eptic Tank ® Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑-iVo If yes,was 3t cleaned? ❑ Yes ❑ Na
5. Condition of System:
6: System Pumped By:
Nell.Bateson 1=5821
Name Vehicle License Number
Bateson Erste rises Inc
Company
7. Locatio a re contents-were disposed:
GLS Lowell Waste Water
I Na SAE
to •—r
2F
Sign a HiaulwU Date
l5form4.doc•08103 System Pumping Record•Page'i of 1