HomeMy WebLinkAboutSeptic Pumping Slip - 1 SCOTT CIRCLE 11/17/2015 Commonwealth of Massachusetts
4 City/Town of .
k y' to u pin sec r-
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 hous : Rigkt. ear of oq se Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/RlgHt rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town State mow(/ Zi e
Telephone Number
.B. Pumping Record
1. Date of Pumping 2. Quantity-Pumped:
Date Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yas ® No If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of Syste
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Lo lion-where contents were disposed:
G-LS.,6 Lowell Waste Water
SignAtufe 9t Haule Date
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