HomeMy WebLinkAboutSeptic Pumping Slip - 209 BRIDGES LANE 10/15/2015 Commonwealth of Massachusetts
City/Town of .
System Pumping-Record
e
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 foram 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/eigl.it�t of ;Left-/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 'N '( r
CiWTown State Zip Code
2. System Owner:
Name
Address(if different from location)
CitylTown ' State ipode
Telephone Number
B. Pumping RRecord
1. Date of Pumping 2. Quantity Pumped:
Date Gallons y
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? No If yes, was it cleaned? ❑`"Yes ❑ No,
5. Condition of System:
6: System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
'A',LS-P Lowell Waste Water
SignAqe qt Haule Date
06rm4.dov 06/03 System Pumping Record•Page 1 of 1