HomeMy WebLinkAboutSeptic Pumping Slip - 104 SHERWOOD DRIVE 9/10/2015 .�L\ 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: Le f�t�fro )Left/Right rear of house, Left/right side of house, Left/
Right side of building. Rlding, Left/Rig ht rear of building, Under deck
Address �(� �.� l<�V\•� ^-``C1� --�'��C��` ,,. '�-�°-
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State �e /r'7 _Code ;
f C
r'S
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of s
yp stem:y. ❑ Cesspool(s) eptic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep a<0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sys m / r
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati n her contents-were disposed:
G L S Lowell Waste Water
Sign a cfHauleV Date
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