HomeMy WebLinkAboutSeptic Pumping Slip - 180 MILL ROAD 12/17/2015 Commonwealth of Massachusetts
City/Town of IRA,,
System tem Pumping.Record
Form 4
DEP has provided this form*for use-by local Boards of Health. Other forms may be'used, b'but the
information-must be substantially the tame 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 house, Left Left right side of house, Left
Right side of building, Left Right front of building, Left Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityrrown state- Z* Code
Telephone Number
B. Pumping Record
1. Date of Pumping bate 2. Qu6ntipy Pumped:
Gallons
3. Type•of systerrt. ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present.? ❑ Yep 0-14o' If yes, was it cleaned? E] Yes ❑ No,
5. Condition of System:
VN
6.. System Pumped By:
Nell.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where
contents were disposed:
k G L Lowell Waste Water
Sign We ct Haul.iU Date
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