HomeMy WebLinkAboutSeptic Pumping Slip - 81 BRADFORD STREET 12/2/2015 7
Commonwealth of Massachusetts
v City/Town of .
YS tem 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 t
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
I. System Location: Left/<Right front of hot , Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right ont of building, Left/Right rear of building, Under deck
Address
City/,rown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown ' State Zi�C:dde
i
Telephone Number
B. Pumping Record * .
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system: ❑ Cesspool(s) 0 Septic Tank [I Tight Tank
❑ Other(describe):
p ❑ Yes ❑w° ",,.,,
4. Effluent Tee Filter resents o If yes, was it cleaned? E] 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:
U
LS-P LS-P Lowell Waste Water
SignAtufa I Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1