HomeMy WebLinkAboutSeptic Pumping Slip - 78 VEST WAY 12/2/2015 Commonwealth of Massachusetts
= City/Town of .
ystern 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 l
the local Board of Health or other approving authority.
A. Facility Information _
1. System Location: Left/Right front of house, Left ht rear of hour", Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear cif building, Under deck
Address
Cityfrown 1, state Zip Code
2. System Owner:
Name' Tr-
Address(if different from location)
C !C?C e
Citylrown ' State;.w�
Telephone Number
r
B. Pumping Rgcord µ ..
1. Date of Pumping Date 2. Qual, ity Pumped:
Gallons .
3. Type-of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye,50 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:
O S.P Lowell Waste Water
,, ,w.. . �
Sign a 9t Hauleqj Date
06=4.doc•06/03 System Pumping Record•Page 1 of 1