HomeMy WebLinkAboutSeptic Pumping Slip - 329 REA STREET 11/17/2015 Commonwealth of Massachusetts
City/Town of .
4° 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: !� /Righ ront of ti e, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Rig-ht front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown ' State A - Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons Y
3. Type-of system: ❑ Cesspool(s) ❑-°Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ N,o ~ If yes, was it cleaned? ❑ Yes ❑ No
" 5. Condition of System:
• it y�� t/��J�. ` � '�!3-�
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati where contents-were disposed:
GLS-Q Lowell Waste Water
5
Sign a 9t HaulerU Date
06rm4.doc•06/03 System Pumping Record•Page 1 of 1