HomeMy WebLinkAboutSeptic Pumping Slip - 72 PATTON LANE 12/4/2017 Commonwealth of Massachusetts
y City/Town of .
System Pumping-Record
Form 4
DEP has provided this form for usepby local Boards of Health. Outer 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 forret they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. InforMafion
1. System Location: Loft/Right front of Rause, Left l 1 ht rear of hou , Left/right side of house, Left I
Right side of building, Left/Right front of building, Left 1 Right rear df building, Under deck
_ Address
CityfTown State ®IlJ zip Code
2. System Owuner. �•� �� -
Name:'
Address(if different from location)
CityfTown _ stater
Telephone Number
i
.B. Pumping Rkcord `
1. Date of Pumping 2. Quanti Pum ed: `
Date Gaitans 4-�
3. Type-of system: ❑ Cesspool(s) ptic Tank [] Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
b. Condition of Syste : `
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle tieense Number
Bateson Ehtefl2rlses Inc'
Company
7. Location whew contents-were disposed:
GL S Lowell Waste Water
F
Sign a Hauf Date
t5form4.dor.-06103 System Pumping Record•Page i of 1