HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 116 CHRISTIAN WAY 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 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 '�/RW!gqht
r of hoif
, Left/right side of house, Left
Right side of building, Left/Right front of building, Left rearbuilding, Under deck
Address
City/Town l5 Zip Code
2. System Owner.
Name"
Address or different from location)
City/Town
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System- ` b Vud
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio a contents were disposed:
L S Lowell Waste Water
Cam_ -C?
Signkje cfHauleiUDate
tftrm4.doc•06/03 system Pumping Record•Page 1 of 1