HomeMy WebLinkAboutSeptic Pumping Slip - 185 BRIDGES LANE 12/18/2015 Commonwealth of Massachusetts I
o i
i ,/Town of
YS tem Pumping,Record
Form 4 vN
�• DEP has provided this form for us&by local Boards of Health. Other form's may be d,
e ,'�� .
'use but the 1
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: Left/Right front of house, Left/Right rear of house, Left Ig6t side of houses Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address -
Citylrown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State w W.< dip Code
Telephone Number '
B. Pumping Rpcord :.
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yap 0-140 If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System: �(
6: System Pumped By:
Neil.Bates F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
.L
S-P Lowell Waste Water
Sign a Haul, Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1