HomeMy WebLinkAboutSeptic Pumping Slip - 20 COLONIAL AVENUE 11/17/2015 : Commonwealth of Massachusetts
_ City/Town of .
System Pumping-Record
Form 4
DEP has provided this form for usezby 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: 'ef�J gig ront of ho s Left/Right rear of house, Left/right side of house, Left/
Right side of buil ng, Left/Rig ron o building, Left/Right rear of building, Under deck
Address
CityfTown State Zip Code i
I
2. System Owner.
Name'
Address(if different from location)
city/Town State Zip Code
Telephone Number
i
• i
B. Pumping JRgcord ..
l C
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system. ❑ Cesspool(s) FTISePtlic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? �yY M
p ❑ Yes ID 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,Wbere contents were disposed:
''G L S'. Lowell Waste Water
L-MIOA P,-)
Signj a cf Haule Date
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