HomeMy WebLinkAboutSeptic Pumping Slip - 1491 TURNPIKE 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 house, Left/Right rear of house, Left/ h side of e, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
U_j
en
Name'
Address(if different from location)
CitylTown ' State
Telephone Number
II �
lr
B. Pumping Rpcord
1. Date of Pumping Date 2• Q rSfity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L9'No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of.System* I
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle license Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
CL S. Lowell Waste Water
Sign a 9t Hiiuleqj Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1