HomeMy WebLinkAbout- Septic Pumping Slip - 90 LOST POND LANE 11/26/2018 Commonwealth of Massachusetts
�EZECI:'D ED
City/Town of
System PumpIng Record
Form 4 j,,jqo011ER
D
DEP has provided this form for use-by local Boards of Health. Other forms may'beused, 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: Leh/Rlgt r-b-fft-o-ih`oust eft i K Ight rear of,house, Left/right side of house, Left I
ildi
Right side of building, Left Righiftr6ni of b lkhrig, left Right rear of building, Under deck
Address
City/Town state Tip—Code
2. System Owner
Name
Address Of different from location)
City/Town State,
telephone Number
.13. Pumping ftecord
1. Date of Pumping Date 2. Quo'n'titvPumped: Gallons
"'u
3. Type-of system: Cesspool(s) 0-�eprtuccTank 0 Tight Tank
0 Other(describe):
4. Effluent Tee Filter present?, E] Yes o If yes, was it cleaned? El Yes El No
5. Condition of System:
6. System Pumped By:
Nell.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises_Inc
Company
7. Lo C—)n--W" er content&were disposed:
G.L S. /7 Lowell Waste Water
Sign Hhul—Ae l5fbrm4.doc-08/03 System Pumping Record-Page 1 of 1