HomeMy WebLinkAboutSeptic Pumping Slip - 370 SUMMER STREET 10/26/2015 Commonwealth of Massachusetts
City/Town of
System Pumping-Record
Form 4 1
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.
A. Facility. information
1. System Location: Left/Right front of housed Lefty Right r of.
g Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address Zip Code �..
City/Town State p
2. System Owner. 4
Name'
Address(if different fr m loca ion
. �`,� � irk ,�
citylrown ' State .• Zip Code
Telephone Number r ,
B. Pumping record
rr „
1. Date of Pumping pate ` 2• Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ®-geptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [3"14o
If yes, was it cleaned? F1 Yes ❑ No;
5. Condition of Jstem: ` pp
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc RECEIVED
Company
7. Location-where contents-were disposed: 0(;,.�.. l 0.l y
Lowell Waste Water
1EALTH DEPARTMENT
Sign a Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
