HomeMy WebLinkAboutSeptic Pumping Slip - 50 SAW MILL ROAD 12/17/2015 Commonwealth of Massachusetts
_ City/Town of
System Pumping-Record `
Form 4
DEP has provided this form for use$by local Boards of Health. Other forms ma 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 Left Left Rg u I
a of houe Left
din side of building, R Right of Left/Right rear of b ng, Un der /
dec
Address
Citylrown State Zip Code
2. System Owner.
Lem 1� a
Name
Address(if different from location)
Ci /Town '
tY � State i de
t `.
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
✓Y.
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
Sign a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
I