HomeMy WebLinkAboutSeptic Pumping Slip - 186 INGALLS STREET 12/2/2015 li
Commonwealth of Massachusetts 1
City/Town of
YS
to Pumping-Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be'used, but the t
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the fortis 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,c e ightqf,afof hour, 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. ?` °
( fry
Name
Address(if different from location)
City/Town ' State Zip Code
Telephone Number t
t
B. Pumping Record ..
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) e ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0—N6' If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System:
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents were disposed:
G L S.. Lowell Waste Water
Sign a I-Haule4j Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1