HomeMy WebLinkAboutSeptic Pumping Slip - 39 GRANVILLE LANE 10/15/2015 i
Commonwealth of Massachusetts RECEIVED
_ . City/Town of . w, Aw ,� ,/0 1 15
Y tem Pumping.. Record
Of" i
Form 4 HEALTH EPARTMv N'r
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
the local Board of Health or other approving authority.
1
A. Facility Information
1. System Location: Left/ ,..� Right Left 1 Right rear of house, Left/right side of house, Left/
Right side of building, Left/ g f uilding, Left/Right rear of building, Under deck
Address
"-> " c, LV\
City/Town State Zip Code
2. System Owner. `.
rN
Name'
r
Address(if different from location)
Cityrrown Stat Zi de
Telephone Number ; d
1
.B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons y
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No if yes,was it cleaned? 0-'Ye's
❑ No
f System
5. Canditio o
�,.
6: System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L : Lowell Waste Water
SignAtu a 9t HaulerLf Date 1
t5form4.doc-06/03 System Pumping Record•Page 1 of 1