HomeMy WebLinkAboutSeptic Pumping Slip - 112 COLONIAL AVENUE 11/10/2015 Commonwealth of Massachusetts
City/Town of .
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 Locatio . Le igh fron �house Left/Right rear of house, Left/right side of house, Left/
Right side of bui g, Left/Righ ildirig, Left/Right rear of building, Under deck
Address
u a L� �c
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town Stag r r . dew
Telephone Number
B. Pumping Record .
1. Date of Pumping Date 2. Quantity Pumped: Gallons �
3. Type-of system: ❑ Cesspool(s) afeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ Na
' 5. Condition of System:
I
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo, ',"�here
caUD
contents were disposed:
G L S'. Lowell Waste Water
Sign a 9t Haulejj Date
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