HomeMy WebLinkAbout- Septic Pumping Slip - 20 COLONIAL AVENUE 11/26/2018 iVED
Commonwealth of Massachusetts 1"'tUX
City/Town of
System Pumpung Record OF�
Form 4
HEA11H
DEP has provided this form for use=by local Boards of Health. Other forms maybe'used, 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 tc)
the local Board of Health or other approving authority.
A. Facility Inform' sition
1. System Location Rlgt#-r ui�, Left/Right rear of house, Left/right side of house, Left I
Right side of bull�&g-, Left I k6i t front R building, Left/Right rear of building, Under deck
Address
/VC
cityfrown State zip code
2. System Owner.
Name'
Address(if different from location)
ClWown state& Code
Telephone Number
B. Pumping Kecord
1. Date of Pumping Date — 2. Quantity Pumped: Gallons
3. Type-of system: Cesspool(s) �Septic Tank DTight Tank
0 Other(describe):
4. Effluent Tee Filter present-7 [01 Yes olwo If yes, was it cleaned? El Yes Ej No
5. Condition of System- k)
6. System Pumped By:
Nell.Batesion F5821
Name Vehicle License Number
Bate§o i Ehte!prises Inc'
Company
7. Loca""'tion-wherp,contents-were disposed:
" �1'1 ,� )
Lowell Waste Water
I plp_nr 7�)
Sign a
t6fbrm4.doo-08/03 System Pumping Record Page 1 of 1