HomeMy WebLinkAbout2016 SEPTIC PUMPING SLIP Commonwealth of Massachusetts RECEIVED
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City/Town of .
System Pumping-Record LJ 1 / � i ��
Form 4 :v � ��.�w�l
l .i,i 6,J yy.VV:rE
y � ..111 � J�.I
DEP has provided this form for use=by local Boards of Health. Other form's 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 t front of Mouse, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/RtghtTfont Of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2: System Owner:
Name
Address(if different from location)
City/Town State ItC Z'
i sa
Telephone Number
1
,F
I.
B. Pumping JPecord y.
1. Date of Pumping bate 2. Quan`ty-pumped:
Gallons -`
3. Type,of system: ❑ Cesspool(s) ® eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
6. Condition of System:
6; System Pumped By:
Nell.Batesion F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo tierrere contents were disposed:
Q L S'. Lowell Waste Water
c lee)
Sign a Houle Date
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