HomeMy WebLinkAboutSeptic Pumping Slip - 481 REA STREET 12/2/2015 Commonwealth of Massachusetts
City/Town of .
S YS
i to Pumping-Record
Form 4
DEP has provided this form for usezby 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 house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State 'Zip Code
2. System Owner.
N4.. ., ,.
Name y
Address(if different from location)
Cityrrown ' State Zi Cd e ;
f Telephone Number r
l,
B. Pumping JRecord Cl
1. Date of Pumping 2. Quantity Pumped:
Date , Gallons
3, Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes E]"'No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati . .where contents were disposed:
G L S: ` Lowell Waste Water
OrcsA 4r
Signitufe fHaulev Date
t5form4.doc•06/08 System Pumping Record•Page 1 of 1