HomeMy WebLinkAboutSeptic Pumping Slip - 32 SOUTH CROSS ROAD 9/24/2015 1
Commonwealth of Massachusetts
= City/Town of .
y• tem 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 hour. ttt1tigh � of house; Left/
Right side of building, Left/Right front of building, Left/Right rear of�u�i in Under de ck..... '
Address
n
Citylrown State Zip pde
2. System Owner ..m,
Name'
Address(if different from location)
C!Wrown ' State Zip a..
Telephone Number
B. Pumping in Record
p 9 �
1. Date of Pumping 2. Quantity Pumped:
Date Gallons y �`
3. Type-of system: ❑ Cesspool(s) 3—Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0-1�6 If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: a
6: System Pumped By:
Neil,Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7 Location.where contents-were disposed:
Lowell Waste Water
cr ....._
Sign a Haule Date
t5form4.daa 06103 System Pumping Record•Page 1 of 1