HomeMy WebLinkAboutSeptic Pumping Slip - 162 HAY MEADOW ROAD 11/24/2014 Commonwealth of MassachUsefts
u City/Town q
G System Pumping
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
kcal Board of Health to determine the form they use.The System Dumping Record must be submitted to
the local Board of Health or ether approving authority.
A. Facift Information
1. System Location: Left/Right front of house, Left ht rear of hour Left/right side of house, Left/
Right side of building, Left/Right front of buildidg, Left ghf rear of building, Under deck
Address
Cityrrown Mate Zip Code
2. System Owner:
Name
Address(if different from location)
ia
City/Town - stat ! hod
Telephone Number
B. Pumping Record
1. Date of Dumping Date 2. Qua 'ty Dumped:
Gallons ®�
. Type of system: Cesspool(s) Septic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes No If yes, was it cleaned? Yes No
5. Condition of Sy tem: '
M
6. System Dumped By:
Neil 6ateson F5621
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo hcontenta were disposed:
G L Lowell Waste Water
sign t ®ate
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