HomeMy WebLinkAboutSeptic Pumping Slip - 181 LACY STREET 12/2/2015 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
I. System Location: Left/Right front of house, Left sd, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
. Address
r
Citylrown State Zip Code
2. System Owner:
vv
Name'{
b fr
Address(if different from location)
iCitynown $tat Z Code
Telephone Number
.B. Pumping Record
tk - `.
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of s stem:
yp y. ❑ Cesspool(s) Tank El 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:Y Lowell Waste Water
Sign a Haule Date f
�i
t5form4.doc•05/03 System Pumping Record•Page 1 of 1 f
i