HomeMy WebLinkAboutSeptic Pumping Slip - 54 VEST WAY 12/18/2015 i
Commonwealth of Massachusetts
z �
City/Town of .
System Pumping,Record
r Form 4
DEP has provided this farm far useyby 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 •
1. System Location:(�e6 fight front of house, Left, h �ror ousy Left/right side of house, Left Right side of building, Left/Right front of building, Left/R 'of building, Under deck af
. Address r� y � � �--- � C".>w;�,,
CWTown State Zip Code
2. System Owner:
Name'
Address(if different from location)
citylTown ' State Zip de ;
Telephone Number
s i
9
B. Pumping Rpcord �- �� .^ � 1 � -� �•
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) EY Septic Tank ❑ Tight Tank
❑ Other(describe): �-
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of.System- CA
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Loca' w r contents were disposed:
Lowell Waste Water
Sign a Hanle Date
t5form4.doc•06/08 System Pumping Record•Page 1 of 1