HomeMy WebLinkAboutSeptic Pumping Slip - 20 NORTH CROSS ROAD 10/15/2015 Commonwealth of Massachusetts
_ City/Town of
S stem Pumping-Record � �
Form 4 OF 0A Wo
DEP has provided this form for us&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
the local Board of Health or other approving authority.
A. Facility Information
I. System Location: Left/Right front of house, Left/Right rear of houseLe, /fight sire of housb, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck-""
Address 4.,
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown ' State p e
ev
• .. . ..
Telephone Number +�
lrJ
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) 0 Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent?
p ❑ Yes Er"No If yes, was it cleaned? F1 Yes ❑ No; �
' 5. Condition of System:
6.- System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
CS:L gHaule Lowell Waste Water
i
Sign a Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1