HomeMy WebLinkAboutSeptic Pumping Slip - 50 WILD ROSE DRIVE 8/27/2015 Commonwealth of Massachusetts
_ City/Town of
System Pumping-Record
Form 4
DE'P has provided this form for use by local Boards of Health. Other or ms,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 forth 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 front of hoys6, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citynown State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State n �Zip Cpdq
31:�> •' 11 ,r"
Telephone Number d
3 1 `
B. Pumping JRecord �
• J.�� � c,�" Cam,
1. Date of Pumping Date 2. Quantity Pumped:
Gallons T
.t.
3. Type-of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank
Cher(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System, ` ,CAS
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Ehterprises Inc-
Company
7. Locatio here contents were disposed:
G L S: Lowell Waste Water }}
SignAqe cf Haule Date
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