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t5form4.doc• 06/03
Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for us&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 to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location Left Righ nt of house eft / Right rear of house, Left / right side of house, Left /
Right side of buil , Left / Right front of building, Left / Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address (if different from location)
City/Town Stat Zip C
I r7 P ry
Telephone Number
B. Pumping Record
I. Date of Pumping Date �epfic
n ' Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes E3 No If yes, was it cleaned? ❑ Yes ❑ No
5. Con itiof System:
11".
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locates ere contents were disposed:
Lowell Waste Water
,uie Date
System Pumping Record • Page 1 of 1