HomeMy WebLinkAboutSeptic Pumping Slip - 167 GRANVILLE LANE 5/24/2016 : Commonwealth of Massachusetts
= City/Town of
System Pumping-Record
Form 4
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
1. System Location: Left/Right front of house, Left rear�hou , Left/righ t side of house, Left Right side of building, Left/Right front of building, Left/Rig building, Under deck
Address
City/Town State Zip Code
2. System Owner.
0 V\-
Name'
Address(if different from location)
citylrown ' State- Zi C .0 ;
Telephone Number
-- 1`
.B. Pumping Record
1. Date of Pumping Date 2. Quanti Pumped: Gallons -`
3. Type-of system. El Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System._• � ^ � � .
U "
A&f%� lC�L11 Zf
6; System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locati here contents-were disposed:
G L�6.,6 Lowell Waste Water
SignAtufe cf HaulerU Date
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