HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 83 LOST POND LANE 11/4/2019 : 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 maybeused,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/ %ig
t of house ft/Right rear of house, Left/right side of house, Left
Right side of building, Left/ n o uildihi Left/Right rear of building, Under deck
Address 73 Los t PG,<�
Citylrom State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State e
Telephone Number
B. Pumping Record
1. Date of Pumping 10 ' — 2. Quantity p Pum ed: t �
Date Gallons
3. Type of system: ❑ Cesspool(s) 3-`teptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: ��r
6. System Pumped By.-
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locafi ffle contents-were disposed:
Lowell Waste Water
Sign a HtkulwuDate
t5fbrm4.doc•06/03 System Pumping Record•Page 1 of 1
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