HomeMy WebLinkAboutSeptic Pumping Slip - 42 BANNAN DRIVE 12/17/2015 Commonwealth of Massachusetts
City/Town of si
A system Pumping.Record ��' �.....
Form 4 J
DEP has provided this form for usetby local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using Ahis 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 eftJ Righ f ont ofjggvse', Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/rown State Zip Code
2. System Owner:
'V -
Name'
Address(if different from location)
City/Town Stater ,_ Zip Code
Telephone Number r 4
B. Pumping Record
� ._. ( .
1. Date of Pumping Date 2. Quantity Pumped: Gallons t
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑o f 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. Location where contents-were disposed:
L Lowell Waste Water
_gi7g_nAhfe ct Haule Date
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