HomeMy WebLinkAboutSeptic Pumping Slip - 161 BRIDGES LANE 12/2/2015 Commonwealth of Massachusetts
j
_ City/Town of
fiystem Plumping-Record
Form 4 1
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
1. System Location: Left/Right front of hous , e R!004-
i re
L ghar of house, Left/right side of house, Left 1 J
Right side of building, Left/Right front of bui�di g, Left/Right rear of building, Under deck
Address ,
Ctty frown State Zip Code
2. System Owner:
Name - �)7
Address(if different from location) `r
City/Town state, µ ap Code ;
Telephone Number i
i
B. Pumping Record MM..
.
1. Date of Pumping Date 2. Quantity Pumped: Gallons r�
3. Type-of system: ❑ Cesspool(s) a,S is Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0,141- if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents were disposed:
LS. Lowell Waste Water
Sign a cf HaulerU Date
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