HomeMy WebLinkAboutSeptic Pumping Slip - 251 GRANVILLE LANE 11/17/2015 :<L Commonwealth of Massachusetts
City/Town of .
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: Left/Right front of douse,Ce Mgh e r o f house; Left/right side of house, Left/
ht side of buildin Left/Ri ht front of buLeft/Rig rear of building, Under deck
Right 9, 9
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown State /�+, Zip Code ;
Telephone Number
i
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped: Gallons _Y
3. Type of system: ❑ Cesspool(s) 0-5eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes M--No If yes, was it cleaned? ❑ Yes ❑ Na
" 5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where_ contents were disposed:
S'. Lowell Waste Water
Sign a I Haulejj Date
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