HomeMy WebLinkAboutSeptic Pumping Slip - 30 SUMMER STREET 12/18/2015 Commonwealth of Massachusetts
z
• ity/Town of
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* tem Pumping-Record
Form 4 �
DEP has provided this form for use-by local Boards of Health. Other forn�ls 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( ?/Rig root of h uo s`, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Righ ofuildirig, Left/Right rear of building, Under deck
Address
+.
City/Town State Zip Code
2. System Owner.
Name*
Address(if different from location)
Cityirown Stat C (ip Code ;
Telephone Number 4
i,
.B. Pumping ,Rpcord --_
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 No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System': p
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. L7L1, re contents
were disposed:
.7
S. Lowell Waste Water
Sign a Haule Date
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