HomeMy WebLinkAboutMiscellaneous - Exception (23)Commonwealth of Massachusetts
City/Town of
a 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 to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
- l
1. System Locatio eft ron ft rear, left si of house fight front, right rear, right side of house.
Address 16
City/Town
2. System Owner.
Name
Address (if different from location)
City/Town
,e� lJo (-4/U,
State
Zip Code
Sta! � g _ � Zip ode
Telephone Number `/Uv
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: 8 Cesspool(s) eptic Tank [j Tight Tank
Other (describe):
4. Effluent Tee Filter present? C] Yes
5. Condition of System:
n
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
leue� -� V-\�
7. Locatier��ntents were disposed:
Lowell Waste Water
If yes, was it cleaned? p Yes [j No
F 5821
Vehicle License Number
JA - <3 —1
of H u r Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1