HomeMy WebLinkAboutSeptic Pumping Slip - 258 BRIDGES LANE 6/16/2016 Commonwe'alth of
RECEIVED
City/Tow
d S S' tem PumpingRecord
Form 4
JMM,f OF r K 1�.�
DEP has provided this form for use;by local Boards of Health. Other faV ' ieq` 'i� e , 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
� . u. fie
Y 9
1. System Location; Left/Right front of house, Left/°. ih ,,fear of g de of house, Left/
0 Right side of building, Left/Right front of building, Left/Right rear of building,
nde„ pR
.
ha , Left/
Address ° ..
Citylrown State Zip Code
2. System Owner.
Name.
Address(if different from location)
cityfrown State „ry ip Code ;
C L
Telephone Number
i
13. Pumping pm c®r
1. Date of Pumping Date C 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
�.... ..
4. Effluent Tee Filter present? Yes El G�No If yes, was it cleaned? es ❑ No,
5. Condition of Sys tem,
VIcyN.* .. .
6: System Pumped By.,
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lop ere contents were disposed:
,
G L S. Lowell Waste Water
Sign a Haule Date
t5form4.doc®06/03 System Pumping Record•Page 1 of 1