HomeMy WebLinkAboutSeptic Pumping Slip - 67 CRICKET LANE 1/25/2016 I
Commonwealth of Massachusetts
City/Town of
t
y� t Pumping. r 1
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.
t
. A. Facility Information
I. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State "Zip,Cbde,
2. System Owner,
Name
Address(if different from location)
city/Town ' State Zip Code ;
f "-
Telephone Number
t
i
B. Pumping Record
1. Date of Pumping Date l 2• Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
[I Other(describe):
4. Effluent Tee Filter present? ❑ Yes 040 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. Location where contents were disposed:
TSIgne Lowell Waste Water
e [lat e
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