HomeMy WebLinkAboutSeptic Pumping Slip - 137 BRIDGES LANE 11/10/2015 Commonwealth of Massachusetts
C4/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 v
1. System Location: Left/Right front of house, Left!Rt rear of hous , Left/right side of house, Left/
Right side of building, Left/Right front of building, building, Under deck
9
Address r
C' town
state Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown ' State p Code
j Telephone Number
B. Pumping JRecord
1. Date of Pumping oat ® Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ;Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
6.- System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locationmliere contents were disposed:
Lowell Waste Water
Sign a Haule Date
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