HomeMy WebLinkAboutSeptic Pumping Slip - 48 PADDOCK LANE 6/16/2016 Commonwealth Massachusetts
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System Pumping,Record
Form 4 �.
DEP has provided this form for use=by local Boards of Health. Other forms may` `e`6sbk"out the
information must be substantially the tame as that provided here. Before using.this form, check with your
1oc61 Board of Health to determine the forrn they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facill.ty Information
1, System Location: Left/Right front o nt of bet* Left/Right r`ao Q eAeft/right side of house, Left/
h
Right side of building, Left/Right fro g, g r f building, Under deck
Address
�. ,.. ..,. . .. 1 .. � " ;
r
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityrrown State ""µ Zip Code
Telephone Number
B. Pumping Rgacord
r,
1. Date of Pumping pate 2. Quantityr,Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste
B elle" ` V\,
6: System Pumped By:
Neil.Bateson F6821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatipri wh a contents were disposed:
Lowell Waste Water
1-44JOA
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