HomeMy WebLinkAboutSeptic Pumping Slip - 133 COLONIAL AVENUE 10/15/2015 ®rnrOnwealth Of Massachusetts
_ City/Town of .
y* tem Pumping rd
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 1
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house, Left L- �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
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/rown • Stat i _....� ..... P° �
Telephone Number
p g
B. Pum in Record � �..
... ._c k ;
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
msµ.,....
4. Effluent Tee Filter present? ❑ Yes o 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 ere contents were disposed:
__LS-P Lowell Waste Water
Ma SA
SignAhie qt Hauie Date
t5form4.doci 06/03 System Pumping Record•Page 1 of 1