HomeMy WebLinkAboutSeptic Pumping Slip - 146 DEER MEADOW ROAD 6/7/2016 Commonwealth u ! E1VED
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Form 4 it r.i I C:rG'��� :��i., ,v� 1�
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 ward 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/1igh front�of haus , Left I Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right fr6nf of building, Left/Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
city/Town State Zif-Code
t
Telephone Number
B. Pumping Record ,•
1. Date of Pumping 2. Quantity Pumped: i---�
Date Gallons
3. Type of system: ❑ Cesspool(s) ❑" Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If es, was it cleaned? '��w� "t�"..,w
y ❑ es ❑ Na,
5. Condition of System: /
w
, 4 ,�,nl+°�.d�^.,.F,... ry ` .�� 3.�:k,,, w � (,.(,..k `w.,,✓'...... "Y �w.s'�...�.Y"4,w.�%w�wwa.
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6: System Pumped Sy:
Neil.Bateson F5821
Name Vehicle License Number
Sateson Enterprises Inc-
Company
7. Locationwub contents-were disposed:
L S; Lowell Waste Water
Sign a Houle Date f
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