HomeMy WebLinkAboutSeptic Pumping Slip - 140 GRAY STREET 9/2/2015 _ 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 i ht rof nt of h u, 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
City/Town State Zip Code
2. System Owner. pp
Name'
Address(if different from location)
City/Town t State- -4�—4`(& Zip Code_
Telephone Number �l `��
i
1;
B. Pumping Record �.
1. Date of Pumping Date ��2,Qua' i ty Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Sptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6: System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location w ere contents-were disposed:
Lowell Waste Water
SignAtufe 9t Hauleqj Date
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