HomeMy WebLinkAboutSeptic Pumping Slip - 18 PENNI LANE 11/17/2015< 7
Commonwealth of Massachusetts I
z City/Town of .
y•'t em 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, Left/tJ'it rear of house', 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.
,75 .
Name'
Address(if different from location)
Cityfrown ' State i Code
t �4,
Telephone Number
i;
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) peptic Tank ❑ Tight Tank
❑ Other(describe):
.m
4. Effluent Tee Filter present? ❑ Yes o 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. Location ere contents-were disposed:
G I.S. Lowell Waste Water
Sign a Haule Date
t5formCdoc-06/08 System Pumping Record•Page 1 of 1