HomeMy WebLinkAboutSeptic Pumping Slip - 116 CHRISTIAN WAY 10/1/2015 I
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Commonwealth of Massachusetts 1
= w City/Town of
L° System Pumping Record
r` 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 i ht rear of housb, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig-ht rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name*
Address(if different from location)
Cityrrown " State ( ;• Zi Code
Telephone Number
i
B. Pumping record �.
C _.
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑4,16 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. Locati AP4 contents-were disposed:
L S. Lowell Waste Water
Sign a I Haule Date
t5form4.dov 06/03 System Pumping Record•Page 1 of 1