HomeMy WebLinkAboutSeptic Pumping Slip - 40 GRANVILLE LANE 12/4/2017 Commonwealth of Massachusetts
4 QtKown 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,,,
the local Board of Health or other approving authority.
A. Facility. Inform' ation
1. System Location: Left/Right froth of House, Left/Right rear of house, Left/right side of house, Left./
0 Right side of building, Left 1 Riglit€ront of buildilig, Left 1 Right rear df building, Under deck
Address
Citylrown state -' Zip code
Z. System Owner.
Name
Address(if different from location)
ciiytrown ' Stat ip,Ca�e
t
r �- -
Telephone Number `
s e
B. Pumping R-pcord
—( `7 cc _
1. Date of Pumping Dake 2. Quantity Pumped:
Gallons F
3. Type-of system: ® Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [] Yes a If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System:
6. System Pumped By:
Neil.Bateson• F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
T, l_ocati0 ere contents were disposed:
^L S: Lowell Waste Water
Sign a �f�ui Date f
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