HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 340 SUMMER STREET 10/16/2019 : Commonwealth of Massachusetts
City/Town of
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 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: Left/Right front of house, Left/Right rear of house, Left/ ht side of house;Left
Right side of building, Left/Right front of building, Left/Right rear of building, n e k--
Address
-5 qo SL)��vv,,v_c
city/rown State Zip Code
2. System Owner.
Name'
Address(i different from locafion)
CiWown Stater-� Zip Code .
a C-,-j— �317S—
Telephone Number
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) .. eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes L_No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of Syst
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
L S Lowell Waste Water
SignAtufe cf HiaulerU Date
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