HomeMy WebLinkAboutSeptic Pumping Slip - 40 DUNCAN DRIVE 5/12/2015 Commonwealth of Massachusetts
= City/Town of
h.
e y• t � i -Record
5�•
Form 4
DEP has provided this form for us&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, .trigh Ide of house Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under ec
Address
t
City/Town State Zip Code
2. System Owner: RECEIVED
Name'
Address(if different from location) TOWN a
HEALTH GCE B::AR I-MEN G
Citylrown State ! Zip Code ;
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons r
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. Conditio of stem: j
�I V1\1
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo here contents-were disposed:
7C L S. Lowell Waste Water
Signitufe Haule Date
06rm4.doc-06/03 System Pumping Record•Page 1 of 1