HomeMy WebLinkAboutSeptic Pumping Slip - 132 CRICKET LANE 12/2/2015 Commonwealth of Massachusetts
= City/Town of .
S 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
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. S y stem Locatio
Rig ronto
�x g f house Left/Right rear of house, Left/right side of house, Left/
Right side of bu IdiFig, Left/Rlg t front of building, Left/Right rear of building, Under deck
Address
• Pi
QC
Cityrrown state Zip Code
2: System Owner, C" ,,y
Name'
Address(if different from location) 71.' l ll)0
cityrrown ' State ' Zi Cod ;
Telephone Number
3 1
B. Pumping ,Record
- f
1. Date of Pumping Date 2. Quantity Pumped:
Gallons r
3. Type-of system. ❑ Cesspool(s) [ Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑w-46" If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6; System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location Where contents were disposed:
C L S Lowell Waste Water
I F
Sign a qf HauleV Date
0=4.doc•06/03 System Pumping Record•Page 1 of 1