HomeMy WebLinkAboutSeptic Pumping Slip - 45 SHANNON LANE 4/24/2018 Commonwealth of Massachusetts
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x nSyitem Pumping,
Form 4
DEP has provided this form for use-by local Boards 'of Health. Other forms may ba bsed,but the
information"must be substantially the tame 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 submltted t®
the local Board of Health or other approving authority.
A. Facility, Information
1. System Location: Lift t front pf Hous Left/Right rear of house, Left/right side of house, Left 1
Right side of building, Left/Rig t ron o building, Left C Right rear of building, Under deck.
Address w � .~
Cit Town Mate Zip Code
2. System Owner:
" Name'
Address(if different from location)
City/Town ' StaZip, '
Telephone Number
r
Pumping
?. ®ate of Pumping Date 2. Quantity Pumped: Gallons t
3. Type-of systerM ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ tither(describe):
4. Effluent Tee Filter present? ® Yep o � If yes, was 4t cleaned? ❑ Yes ❑ No,
' 6. Condition of System:
6.� System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Sate�on �eiterprlses Inc'
Company
7. L71,
re contenta were disposed:
L Lowell Waste Water
' F
Sign a ct Hiaul Cate
t5fom14.doc•06103 System Pumping Record•Page 9 of 1