HomeMy WebLinkAboutSeptic Pumping Slip - 75 GRANVILLE LANE 10/1/2015 Commonwealth of Massachusetts
City/Town of j
S * tern Pumping-Record '�<
Form 4
i
DEP has provided this form for use=by local Boards of Health. Other forms may be'used, but the t
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 f
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 a/dig side"of house; Left/
Right side of building, Left/Right front of building, Left/Right rear of buii d`mg, UndeFdi ck " �`
Address
Cityrrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Citynown ' 3tat Zip Code
Telephone Number
.B. Pumping Record
•
1. Date of Pumping 2. Quantity Pumped:
Date �. Gallons }--`
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
XA.41z,
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location h., re contents were disposed:
G L S Lowell Waste Water
Sign a I Haule Date
j
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