HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 1650 TURNPIKE 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 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 forrh 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/right side of house, Left
Ri�fif side of a in Left/Right front of building, Left/Right rear of building, Under deck
Address /7_� UC � c ' --
Cityfrown l State Zip Code
2. System Owner.
Name"
Address(if different from location)
CitylTown Sfat�, G ! r-�,� Zi Code
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? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: A
6. system Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio contents were disposed:
�L S Lowell Waste Water
sign Awe Haulev Date L
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