HomeMy WebLinkAbout- Septic Pumping Slip - 155 DUNCAN DRIVE 1/8/2019 Commonwealth of Massachusetts
City/Town of f .
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 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 t®
the local Board of Health or other approving authority.
A. Facility Inform' sitlon
1. System Location: Left/Right front of house, Left/Right rear of house, Left,MjG��s�lde�of�ho� Left I
Right side of building, Left/Right front of buildifig, Left Right rear of building, Under deck
Address
City[rown state Zip
Co'.
2. System Owner.
51 V'\
Name
Address(if different from location)
CilytTown State Aip Code
Telephone Number
.B. Pumping Record
I LA-
I. Date of Pumping Date ;'2. Qu6n P umped:
Gallons
optic
3. Type-of system: El Cesspool(s) le Tank Tight Tank
[I Other(describe):
4. Effluent Tee Filter present? El Yes No If yes, was it cleaned? El- Yes [I No
6. Condi* of System:
6. System Pumped By:
Neil Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where content%were disposed:
LL�Sr P -Lowell Waste Water
Sign e WHtul
Date
0=4.doc-06/03 System Pumping Record g Page 9 of 1