HomeMy WebLinkAboutSeptic Pumping Slip - 178 HAY MEADOW ROAD 1/25/2016 i
Commonwealth of Massachusetts
City/Town of .
Y item Pumping.Record
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.
. A. Facility Information
1. System Location Lem`Righfron of ho su )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 gam, �J
. (
City/Town State Zip Code
2. System Owner: l
Name'
Address(if different from location)
citylrown State Zip Code
Telephone Number
B. Pumping Record �
/5
1. Date of Pumping pate 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:
00 '°� 62U'11�4, VAI
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo
cati n wh a contents were disposed:
7_L S'. Lowell Waste Water
Sign a cf Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1 f
