HomeMy WebLinkAboutSeptic Pumping Slip - 22 TIFFANY LANE 9/11/2015 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/Right rear of house,LLea righ ide ► use,left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under dec
Address
City/Town State Zip Code
2. System Owner.
Name*
Address(if different from location)
CitylTown State �2� `� `�e ;
Telephone Number
;
B. Pumping Record .
1. Date of Pumping t r� 2. Quantity umped:
p g Date ty Gallons y
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes []-No If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca' n, ere ontents were disposed: _
G L SJQ Lowell Waste Water
"t1raA
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SlgnAtuTe 9t Haule Date
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