HomeMy WebLinkAboutSeptic Pumping Slip - 11 BRIDGES LANE 11/17/2015 Commonwealth of Massachusetts
city/Town of
System Pumping-Record
Form
4
'for use by local Boards of Health. Other forms may be*used, but the
DEP has Provided this for
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/ fight rear of hous6, Left/right side of house, Left/
Right side of building, Left/Right 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)
State Zip Code
Telephone Number
B. Pumping Record r c�.> .
1. Date of Pumping Date 2. Quantity Pumped: Gallons y
3. Type-of system: ❑ Cesspool(s) is Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes alhlo If yes, was it cleaned? ❑ Yes ❑ No;
5. Condition of System: f � V\, 4t"�
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L77, a contents were disposed:
S. Lowell Waste Water
signi a cf HaulerU Date
t5form4.dov 06/03 System Pumping Record•Page 1 of 1