HomeMy WebLinkAboutSeptic Pumping Slip - 35 SHANNON LANE 5/2/2016 . Pumping.
W. YS %i ' ;' ; U i(
Form 4
DEP has provided this form for use;by local Boards of Health. Other forms may 64,`o dd 4ut the i r
information must be substantially the tame as that provided here. Before using.this form, check with your
local Board of Health to determine the forth 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 Mouse Left iglit rear of ho s ; eft/right side of house Left/
Right side of building, Left/Right front of building,Le Ig of building, Under deck
Address
City/Town State Zip Code
2. System Owner. r.
Name'
Address(if different from location)
City/Town State , Zip Code ;
Telephone Number
13. Pumping lRecor �.
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Typeof system. ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o r if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. system Pumped By:
Neil.Batesan F5621
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G
LS. Lowell Waste Water
/ ,✓ - I
,Sign a Haule Date
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