HomeMy WebLinkAboutSeptic Pumping Slip - 50 LOST POND LANE 9/30/2015 Commonwealth of Massachusetts
City/Town of
System Pumping Record f�J��
Form 4
5 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 forth 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 house, Left/fight de of house,-left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Tc6_4 ..
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State i Code
Telephone Number
t
i
1
.B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons Y
3. Type-of s stem:
yp y. ❑ Cesspool(s) eptic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [Io 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. Location where contents-were disposed:
.L S: Lowell Waste Water
Sign a 9t HaulerU Date
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