HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 42 BANNAN DRIVE 12/12/2019 veec
: Commonwealth of Massachusetts � 19 'l`l`
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 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 Locatio . e ?Rig of house Left/Right rear of house, Left/right side of house, Left
Right side of b ' ' g, Left/ lg ron uildirig, Left/Right rear of building, Under deck
Addre55 r
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citynown State Zi Code
t
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 o 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. LocabmAvbgre contents-were disposed:
L S Lowell Waste Water
-JA Tu-PA
Sign a Haul Date
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