HomeMy WebLinkAboutSeptic Pumping Slip - 116 SHERWOOD DRIVE 5/24/2016 Commonwealth of Massachusetts
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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 douse, Left/ igh�re Crorfe:ho e, Left/right side of house, Left Right side of building, Left/Right front of building, Le Iar of building, Under deck
, Address •� C � ���,��Z.� � �1,�l ry %
CWTown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town • State � - Zi Code ;
Telephone Number V'
.B. Pumping ,Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons r
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lora' re contents were disposed:
G L SWHaule Lowell Waste Water
F
Sign a Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1