HomeMy WebLinkAboutSeptic Pumping Slip - 56 CRICKET LANE 1/25/2016 f
Commonwealth of Massachusetts 1
_ City/Town of .
System Pumping-Record t
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, Lefty I ht rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, L Ig rear f building, Under deck
Address �
CVTown State Zip Code
2. System Owner:
Name
Address(if different from location)
Cityfrown State ,I , , Zip Code ;
Telep(/ho-oe Number
1,.
.B. Pumping Record �
fie`
1. Date of Pumping pate 2. Quantity Pumped: Gallons .--'
3. Type s stem:
yp y. ❑ Cesspool(s) Septic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: Lio
6; System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
G L S Lowell Waste Water
7§ignAqe ct Haule Date
0orm4.doc•06/03 System Pumping Record•Page 1 of 1