HomeMy WebLinkAboutSeptic Pumping Slip - 64 OLD CART WAY 4/11/2016 Commonwealth Pump
Cit�/Town of RECEIVED
S item i r PPi
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may bd°1666d',I56f'&A "!r
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, Le,% h ear of haul Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/ id�it rear®f building, Under deck
Address
city/Town Stat—a Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown ' State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping date 2. Quantity Pumped: Gallons
3. Type-of system. ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter resent? ,...
p ❑ ❑ No If yes, was it cleaned? es ❑ No,
5. Condition of System:
6: system P umped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L S. pA'a Lowell Waste Water
Sign t e Haule Cate
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