HomeMy WebLinkAboutSeptic Pumping Slip - 124 SAW MILL ROAD 11/17/2015 1
Commonwealth Of Massachusetts
City/Town of .
S YS tem umpin g.Record 1
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, l Fri htcfearwof ho `
y g ,....W� g �"� use, Left/right side of pause, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Ctty/Town state Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown State .,., Zip Code
Telephone Number
B. Pumping Rgcord �.
1. Date of Pumping 2. Quantity Pumped:
Date �. Gallons -�
3. Type-of system: ❑ Cesspool(s) ❑ eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑' lo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sys em:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio ere contents were disposed:
.L S: Lowell Waste Water
•
A.,
Signible qf Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1