HomeMy WebLinkAboutSeptic Pumping Slip - 96 FARNUM STREET 12/2/2015 l
Commonwealth of Massachusetts
City/Town of .
System pin Record
Form 4
DEP has provided this form for usezby local Boards of Health. Other form's may be'used, but the j
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/fht rear of houLeft/right side of house, Left/
Right side of building, Left/Right front of building, Left ft/Rig rear cif building, Under deck
Address -
n
CitylTown State Zip Code
2. System Owner.
Name
Address(if different from location) � ;; �, �•
Citylrown State Z Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Canons —`
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No 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 where contents were disposed:
G L S' Lowell Waste Water
SigMeHaule Date F
t5form4.doc•06/03
. System Pumping Record•Page 1 of 1
i