HomeMy WebLinkAboutSeptic Pumping Slip - 962 TURNPIKE STREET 10/26/2015 i
Commonwealth of Massachusetts
Cityrl°own of 1
System Pumping-Record
Form
4
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 house, Leff" fight rear of house Left/right side of house, Left/
Right side of building, Left/Right front of building, Le g f building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
J C"
Name
Address(if different from location)
Cityirown State/ ��Code ;
21 Telephone Number
• 1
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Lallans r
3. Type-of system: ❑ Cesspool(s) Q eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L3" No If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System: _ , q 1 ,.�CEIVED
_161CA11 bu')'C
6. System Pumped By: "I WN CX'NOR R kVqDOVER
HLEA_ H DL„PAUMEIff
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Ina
7. Loca' where contents-were disposed:
G L S: Lowell Waste Water
Sign a Haule Date
t5form4.doo-O8/03 system Pumping Record•Page 1 of 1