HomeMy WebLinkAboutSeptic Pumping Slip - 42 JERAD PLACE 10/15/2015 Commonwealth of Massachusetts
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City/Town of
System Pumping-Record
s+.
Form 4
DEP has provided this form for usezby 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 °Righ nt of 11aus Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front o uildirig, Left/Right rear of building, Under deck
Address "
CitylTown state Zip Code
2. System Owner. °
Name'
Address(if different from location)
Citynown State Zip Code
Telephone Number
;
B. Pumping Record
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 (J,96 if yes, was it cleaned? ❑ Yes ❑ No;
' 5. Condition of System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatior where contents were disposed:
Lowell Waste Water
SignAtufe 9t Hanle Date
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t5form4.doc 06103 System Pumping Record•Page 1 of 1
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