HomeMy WebLinkAboutSeptic Pumping Slip - 121 OLD CART WAY 12/18/2015 Commonwealth Of Massachusetts
= City/Tcwn of
System Pumping-Record
Form 4
DEP has provided this form for use:by 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: Left Might front of hour � Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Righ ron o building, Left/Right rear of building, Under deck
y
Address
City frown State Zip Code
2. System Owner:
Name
Address(if different from location)
i
Cityrrown ' State Zip Code ;
• F :tip
Telephone Number +
• i
B. Pumping Record
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? ❑ Yes ® No If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of Sys# m:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
_Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
Lowell Waste Water
Sign a qf Haule Date
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