HomeMy WebLinkAboutSeptic Pumping Slip - 427 SUMMER STREET 12/17/2015 i
Commonwealth of Massachusetts
9R) City/Town of
System Pumping-Record t
Form 4
o,
DEP has provided this farm 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 hous I Righ�gr of ho a"�t Left/right side of house, Left/
Right side of building, Left/Right front of Left/Right rear of building, Under deck
Address s
CiWrown state Zip Code
2. System Owner:
L 0 tL
Name'
Address(if different from location)
CitylTown • state Zip Code ;
SSQ S
Telephone Number
B. Pumping record
1. Date of Pumping Date Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ 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.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
C_L'S "� Lowell Waste Water
Sign "Haule
t5form4.doc-06/08 System Pumping Record•Page 1 of 1
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