HomeMy WebLinkAboutSeptic Pumping Slip - 123 MARIAN DRIVE 10/15/2015 Commonwealth of Massachusetts
City/"Town of
S YS to uin g.Record :� :
Form 4
DEP has provided this form for use=by local Boards of Health.
Other fos may be'used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
Ioc 'I 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/ rear of house Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Righf Wear of building, Under deck
Address
, � '.: ""a ,.•
Kai - "
. . _,�..
Citylrown State Zip Code
2. System Owner.
i
Name
Address(if different from location)
city/Town State Zip Code ;
` G
Telephone Number
1
B. Pqmping Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons y�`
3. Type-of system: ❑ • Cesspool(s) eptc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? s ❑ N
5. Condition of tem:
' �°'.•.,`� �" �. ..gym"
6. System Pumped By: ,. .
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location...wh wcontents.were disposed:
Lowell Waste Water
Sign a Haule Date
t5form4.doc 06/03 System Pumping Record•Page 1 of 1