HomeMy WebLinkAboutSeptic Pumping Slip - 136 SAW MILL ROAD 6/21/2016 Commonwe.alth
RECEIVED
Cit�/Town of
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YS
i t i r d UN r, fj
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.w Form 4
i VJ.i a n::F>,r l �r�,��..
DEP has provided this form for use=by local Boards of Health. Other forms maybe used, bu 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
Right side of building, Left/Right front of building, Left/Right rear of building,Und d deck Left/
1. System Location: Left/Right front of douse Left/Right rear of hous. `
lJnder deck
Address f .....� r,� � �
city/Town State Zip Code
21 System Owner.
Name'
Address(if different from location)
Cityrrown ' C:% ;
State w �� Zip de
y Telephone Number
® Pumping., ecor
w
1. Cate of Pumping Date 2. Quantity Pumped:
Gallons —�`
t
3. Type-of system: ® Cesspool(s) ❑-,Septic Tank ❑ Tight Tank
❑ Other(describe): ..
4. Effluent Tee Filter present? E I Yes ❑ No If yes, was it cleaned? MYes ❑ No,
5. Condition of System:
. "V
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G L S'. Lowell Waste Water
�M C-1 a
f
Sign a I Haule Date
t5form4.doc-06/03 System Pumping Record Page 1 of 1