HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 40 SUGARCANE LANE 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 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: Left Right fron�house,, eft/Right rear of house, Left/right side of house, Left/
Right side of building, Le ig 1ing, Left/Right rear of building, Under deck
Address
Cityrrown "State Zip Code
2. System Owner.
Name c
Address(if different from location)
CitytTown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Q ntity Pumped-
Date Gallons y
3. Type of system: ❑ Cesspool(s) ;-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Q No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio-where contents were disposed:
G L S Lowell Waste Water
Signitute 9t HauleU Date
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