HomeMy WebLinkAboutSeptic Pumping Slip - 136 BRIDLE PATH 9/16/2015 : Commonwealth of Massachusetts
_ City/Town of .
System Pumping.Record
Form
4
DEP has provided this form for uset 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 Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left 1 ftont us Left/Right rear of house, Left/right side of house, Left Right side of building, Left t f buildin g, Left/Right rear of building, Under deck
- Address � � � A
City/Town �f State v` Zip Code
2. System Owner.
Name'
Address(if different from location)
cityfrown State Aip Code ;
Telephone Number
.B. Pumping JRpcord �.
1. Date of Pumping Date 2. Quantity Pumped: Gallons y�
3. Type-of system. ❑ Cesspool(s) ❑ Septic Tank T" ht Tank
ther(describe):
4. Effluent Tee Filter present? ❑ Yep ❑ 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 where contents-were disposed:
,. S Lowell Waste Water
SignAtufe 9t Htiuleqj Date
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