HomeMy WebLinkAboutSeptic Pumping Slip - 55 TIFFANY LANE 9/22/2015 f
Commonwealth of Massachusetts
City/Town of .
y' tern 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 Locatio ; Le Rig front of house Left/Right rear of house, Left/right side of house, Left/
Right side of butleft/ o building, Left/Right rear of building, d
�� 9 n Under deck
g 9�
Address
City/town State Zip Code
ira
2. System Owner:
Name'
Address(if different from location)
Citylrown State t i Code ;
Telephone Number 1
B. Pumping Record
1. Date of Pumping Date 2• Quantity,_Pumped: Gallons
3. Type system*.yp y. ❑ Cesspool(s) eptic Tank Fl Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0,14o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste
6. System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca hipre contents were disposed:
G.L S: Lowell Waste Water
r
Sign a 4fH aute pate `
t5form4.doc•08/03 System Pumping Record•Page 1 of 1
1