HomeMy WebLinkAboutSeptic Pumping Slip - 75 DUNCAN DRIVE 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 Location: Left/Right front of housde�ft�/Rig ear of hous Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/rown State Zip Code
2. System Owner. rr
: T�
Name
Address(if different from location)
Citylrown State/; ip Code ;
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [3 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. LoCali where contents were disposed:
G L S: Lowell Waste Water
SignAtube 9t Haule Date F
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