HomeMy WebLinkAboutSeptic Pumping Slip - 27 OAKES DRIVE 11/10/2015 Commonwealth of Massachusetts
City/Town of
System Pumping.Record
Form 4
DEP has provided this formlor use-by local Boards of Health. Other forms may be'used, b'but the
information-must be substantially the tame 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, Left I ht Mff ofjj�, Left right side of house, Left
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner:
Name
Address(if different from location)
cityrrown State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Q_ifity Pumped: Gallons
Date ----71-
3. Type-of systefff. ❑ Cesspool(s) B-6eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present.? ❑ Yep a'go` if yes, was it cleaned? ❑ Yes r_1 No
' 5. Condition of System:
6.- System Pumped By:
Nell Batesbn F5821
_Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
j a Lowell Waste Water
_65_nku.Te qf HauleV Date
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