HomeMy WebLinkAboutSeptic Pumping Slip - 80 LOST POND LANE 6/6/2016 wealth of Massachusetts
Common
_ City/Town of City/Tow .
JUN I
S item YS
Pumping,
_
Form 4 1f'OWN OF ifIoYNDM,,!R
ilk.A€.Tk�f L)a'.i•Y1P'.P,A[ Tr
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. 1 r ti
1. System Location: Left/Right front of house, Left 13ioht rear of house Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear®f building, Under deck.
Address 4SO ("
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town ' Statec Zi Code
e e- d"
Telephone Number —r
i
_ lrJ
13. Ppmping Rqcord
1. Date of Pumping crate 2. Quantity Pumped: Gallons
3. T e•of s stem: `
yp y• ❑ Cesspool(s) eptic Tank El Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? E] Yes ❑ No.
5. Condition of.System:
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location a contents were disposed:
G L S. Lowell Waste Water
Sign a HaulerU Date
t5form4.doc•06/03 System Pumping Record Page 1 of 1