HomeMy WebLinkAboutSEPTIC PUMPING SLIP (3) Commonwealth of Massachusetts
_ C4/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 Rig t rear of h uo , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
CwTown State Zip Code
2. System Owner.
Name*
Address(if different from location)
cityfrown State ip Code
r'4
Telephone Number
B. Pumping JRecord �.
1. Date of Pumping Date 2- antity Pumped: gallons Y
3. Type-of system. El Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Sys 1v VA-
6.- System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo lien w e contents-were disposed:
G L Lowell Waste Water
f
Sign a 9t Haule Date
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