HomeMy WebLinkAboutSeptic Pumping Slip - 353 PLEASANT STREET 1/12/2016 1
Commonwealth of Massachusetts
City/Town Of .
YS to u pin Record
y` Form 4
DEP has provided this form for use by local Boards of Health. Other forms may *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�641/rig side of house?Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 4 M
e,r
City/rown State Zip Code
2. System Owner
f (�
Name'
P � �r
Address(if different from location)
City/rown State Zip Code
Telephone Number
i
B. Pumping lRecord �
1. Date of Pumping Date 2 dhtity 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. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location Wvhe a contents were disposed:
G_l:.S. Lowell Waste Water
Sign a H—au Ia Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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