HomeMy WebLinkAboutSeptic Pumping Slip - 141 STONECLEAVE ROAD 5/13/2016 Commonwealth f Massachusetts
City/Town f . RED- .j
System Pumping,Record
Form 4
DEP has provided this fora for usezby 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
1. System Location: Left/Right front of house, Leftr k.; t rear of housee left•/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address w .
City/Town State Zip Code
2. System Owner: C c
Name
Address(if different from location)
city/Town Statew�. ip Code J
Telephone Number
3
. P ping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons a�
3. Type of s stem: ❑ Cesspool(s) ❑"` "Sepp 1 c.
Tank ❑ Tight Tank
❑ Other(describe):
resent? Yep 0-' y❑ ..•..
4. Effluent Tee Fitter P Na If es, was it cleaned ❑ Yes ❑ No,
5. Condition�f tem:
w `
6. System Pumped By:
Neil.Batesan F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Locatio,Rwwhere contents were disposed:
4,L S'. Lowell Waste Water
SignAtufe Haule Date
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