HomeMy WebLinkAboutSeptic Pumping Slip - 2240 TURNPIKE STREET 10/26/2015 Commonwealth of Massachusetts
city/Town of
YS
tem Pumping Record
• � - Form
4
n DEP has provided this form for use>by local Boards of Health. Other forms may be'used, but the
a 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. I
A. Facility. Information
1. System Location: Leftt�iront of hou Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address T 0 i p
Citylrown
State Zip Code
2. System Owner:
Name'
Address(if different from location)
citylrown Stat Zi Code
Lj Telephone Number
• i
1
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ 'e-spool(s) q Septic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yep ❑ No If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
N
A
vt
6. System Pumped By:
0C :° ry f.r m
Neil.Bateson ' F5821
Name Vehicle License Number TOwrq OF.NORI.HMOO VE-
Bateson Enterprises Inc HFALTH DEPARTMENT
Company
7. Location where contents were disposed:
Lowell Waste Water
Sign a Haule Date
t5form4.dov 08103 system Pumping Record•Page 1 of 1