HomeMy WebLinkAboutSeptic Pumping Slip - 145 CRICKET LANE 10/15/2015 Commonwealth of Massachusetts
_ ity/Town of .
yste m Pumping-Record
card
y,
Form 4
DEP has provided this form far 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 house, Left./right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Cityrrown state Zip Code
2. System Owner.
Name'
Address(if different from location)
citylrown Stat i Zip Code
Telephone Number
3 1
1
B. Pumping JRecord �.
1. Date of Pumping at 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ptic e Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System• G
6: System Pumped By
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location . here contents were disposed:
,6LS-QV Lowell Waste Water
LfflOA. l e�)_ t
Sign a cf Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1