HomeMy WebLinkAboutSeptic Pumping Slip - 164 BRIDGES LANE 12/28/2015 : \ uommonWeann W massacnuSeus
C4/Town 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
I. System Location: Left/Right front of house, Left/Right rear of house,/rig side of Y ous��eft/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
. Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
citylrown ' StaterQ Zip Code
Telephone Number d
1
B. Pumping Record
-00
1. Date of Pumping 2. Quantity Pumped: l
Date Gaitons Y T
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6.. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L contents were disposed:
Lowell Waste Water
Sign a 9t Haule Date
t5form4.doo•06/03 System Pumping Record•Page 1 of 1
Commonwealth of Massachusetts
= v City/Town of
Y item 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/Right front of house, Left/Right rear of house, Le nigh 'Side hous , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under
Address `"'"t
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State . Code
Telephone Number
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.
5. Conditi�n 9f System: c_
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo iGn-w ve contents were disposed:
G. S. Lowell Waste Water
20A -�o
Sign t e Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1