HomeMy WebLinkAboutSeptic Pumping Slip - 69 OAKES DRIVE 9/14/2015 : 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 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 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/ 1 �ofhous Left/right side of house, Left Right side of building, Left/Right front of building, Left building, Under deck
Address
CWTown State �✓� Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityrrown State _Zip Cede
r'S
Telephone Number
.B. Pumping Record
1. Date of Pumping 2. Quanti Pumped:p g Date ry p Gallons r
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
0-10--t'her(describe):
4. Effluent Tee Filter present? ❑ Yes _ o if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of stem:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents-were disposed:
S. Lowell Waste Water
Z,-MOW
�5
Sign a 9t HaulerU Date
t5form4.doc•06/03 System Pumping Record•Page 7 of 1