HomeMy WebLinkAboutSeptic Pumping Slip - 217 GRAY STREET 8/25/2015 Commonwealth of Massachusetts
City/Town of
S
YS tem Pumping.Record
Form 4
DEP has provided this farm for usezby local Boards of Health. Other forms may be used, b'but the
information-must be substantially the tame 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
A
1. System Location house Left/Right rear of house, Left right side of house, Left
e
Right side of b aig, Left Right front of building, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown state, � Zip Code
• C '?
Telephone Number /*
B. Pumping Record
1. Date of Pumping Bate Z. Quantity Pumped: Gallons
3. Type•of system' [9-50-'ptic Tank ❑ Tight Tank
+�N_AL
'k i J'!=
-
Q-1Other(describe):
4. Effluent Tee Filter present? ❑ Yep ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: --------
V\
6; System Pumped By.,
Nell.Batesion F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati e contents-were disposed:
L '.D Lowell Waste Water
Sign 0"u Date
0=4.doo-06/03 System Pumping Record•Page I of 1