HomeMy WebLinkAboutSeptic Pumping Slip - 222 BRIDGES LANE 10/15/2015 i
Commonwealth of Massachusetts
_ City/Town of .
S YS
* tem Pumping.Record
Form 4
DEP has provided this farm 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
Right side of ion: L L
1. System Location: Left ugh front of housLeft/Right rear of house, Left/right side of house, Left/
g g, eft Ig ron o�tiuildiiig, Left/Right rear of building, Under deck
Address
Bf -A-k-+A
Cityrrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town ' State Zip Code
t Telephone Number
B. Pumping ,Record �
1. Date of Pumping Date �epfic anti umped: Gallons ^ Y
3. Type-of system: ❑ Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of SysrQA
:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location-�e contents were disposed:
Lowell Waste Water
Q3-
SignAWe 9t Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1