HomeMy WebLinkAbout- Septic Pumping Slip - 178 BRIDGES LANE 1/8/2019 .1 L%
Commonwealth of Massachusefts
City/Town of
61"
System Pumping Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe used, but the
information-must be substantially the Berne 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. Facifity information
1. System Location: Left/Right front of house, Left/Right rear of house pright of hous Left I
Right side of building, Left Right front of building, Left Right rear of duldinng, Under:sd�eofq�hous
Address
City/Town state Zip Code
2. System Owner
Noma*
Address(if different from location)
Cityrrown state ----Z:57 ZIP Code
Telephone Number
.13. Pumping ftecord
1. Date of Pumping Date 2. Qui m ty Pumped: Gallons
3. Type-of system: El Cesspool(s) M—Septic Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? Ej Yes EjN`o__ If yes, was it cleaned? Ej Yes E] No
6. Condition of System:
6. System Pumped By:
Nell.BateSbn F6821
Name Vehicle License Number
Bateso i Enterprises Ina
Company
7. Location where contents-were disposed:
Lowell Waste Water
...........
Sign e Hbulwu Date
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