HomeMy WebLinkAboutSeptic Pumping Slip - 178 BRIDGES LANE 12/17/2015 Commonwealth of Massachusetts
City/Town of � ,� „
yitem Pumping,Record
Form 4
DEP has provided this form for use>b local Boards of Health. Other forms may be'used, but the
P Y Y
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. S y s•tem Location: Left/Right front of house�'j /Righb-it' "
Left/right side of house, Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town Skate Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown ' State Zip Code ;
22L I
Telephone Number t
h
B. Pumping Pecord
1. Date of Pumping 2. t antity Pumped: —
Date Gallon ;
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.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locatipn-w—her contents were disposed:
Lowell Waste Water
...
Sign a cf Haule Date
t5forrn4.docr 06/03 System Pumping Record•Page 9 of 1