HomeMy WebLinkAboutSeptic Pumping Slip - 97 SAW MILL ROAD 3/8/2016 Commonwealth u
City/Town of .
Pumping.YS
Form 4
Sys
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
I. System Location: LefttQif$..nf of hous , 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
Citylrown State Zip Code
2. System Owner:
b 0
Name'
Address(if different from location)
i
ti' m gam,ryv w ppp "
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cityrrown b n State ode
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� Zip C ,
Telephone Number �•
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TI'i r Wi 1C 7 C.RI
13. Pumping"Al cord
1. Date of Pumping Date 2. Quanti!y Pumped: Gallons �
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [2-'No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
LAIK-
6. System Pumped By:
Neil.Batesan F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
SignAtuTe I Haule Date
t5form4.doc-06/03 System Pumping Record Page 1 of 1