HomeMy WebLinkAboutSeptic Pumping Slip - 11 BRADFORD STREET 9/17/2015 _ 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 hous a Rig re of hous , Left/right side of house, Left/
Right side of building, Left/Right front of buI ding, Left Ig rear of building, Under deck
9
Address
City/Town State Zip Code
2. System Owner.
Name "--
Address(if different from location)
E
Ci ty frown State e�i Code ;
Telephone Number
i
I
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0-0-0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: �J_
6.. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio here contents-were disposed:
G L S Lowell Waste Water
Sign a Haule Date
t5form4.docr 06/03 System Pumping Record•Page 1 of 1