HomeMy WebLinkAbout- Septic Pumping Slip - 130 MARIAN DRIVE 10/31/2018 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4 OCT 3 12018
TOWMI O�-,
DEEP has provided this form for use-by local Boards of Health. Othet4,qnnsnWzWMfed, 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 forrh 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/Right front of house, Left/Right rear of house, Left./right side of house, Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address r--�
City/Town state Zip Code
2. System Owner:
L
Name'
Address Of different from location)
Civrown State Cod
Telephone Number
,B. Pumping Record
1. Date of Pumping -L62 C 12. Quantity Pumped:
Date Gallons
3. Type,of system: E] cesspool(s) 3-t-e`ptim Tank El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? D-Ye-sE�] No If yes, was it cleaned? [JY5�- [] No
5. Condition of Syst
C- R:,C�A-
t
1
6. System Pumped By: 15
Neil.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati e contents-were disposed:
Lowell Waste Water
Date
t6form4.doc-06103 System Pumping Record®Page 1 of 1