HomeMy WebLinkAboutSeptic Pumping Slip - 48 SUNSET ROCK ROAD 9/15/2015 : Commonwealth of Massachusetts
City/Town of
System Pumping-Record
Form 4
DEP has provided this form for usezby 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 /Rig �o� of house, Left/Right rear of house, Left/right side of house, Left/
Right side of buil id'ng, Left/Right ron o wilding, Left/Right rear of building, Under deck
Address ryq \ `-
City/Town state Zip Code
2. System Owner. `
Name'
Address(if different from location)
CitylTown _ � Stag
Telephone Number
B. Pumping Record .
1. Date of Pumping Date 2. Quantity Pumped: Gallons
,t
3. Type-of system-. ❑ 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 Syst
i
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' are contents were disposed:
G L S: I Lowell Waste Water
Sign a qf Haule Date
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