HomeMy WebLinkAboutSeptic Pumping Slip - 40 SUGARCANE LANE 9/15/2015 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 fight front of hous eft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/ Ig ront of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2: System Owner.
Name
Address(if different from location)
CitylTown State ��� � e ;
Telephone Number
B. Pumping JRecord
1. Date of Pumping oat 2. Quantity Pumped:
Gallons y
3. Type-of system. ❑ Cesspool(s) eptic 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. Locatio. here contents were disposed:
G L S Lowell Waste Water
Sign a Haule Date
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