HomeMy WebLinkAboutSeptic Pumping Slip - 26 STONECLEAVE ROAD 6/13/2016 Common It RECEIVED
u
Cit�/Town of
System r
Form 4
Fl I HU .�/ , �i
DEP has provided this form far use by local Boards df Health. Other forms relay 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, Information
1. System Location: Left/Ri g ht front of house, Left/R'"ht Wrear
®�f house�Left right side of
� whouse, Left
Right side of buildin g, Left Right front of buildin g, Left%Ri g hfrear of building, �nd k /
f .. d
Address � � ..A-7
. -_
" . ., +
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town f State ode ;
ty ✓
Telephone Number
B. Pumping Rpcord ,
1. Date of Pumping ®ate 2. Quantity Pumped: Gallons a�
3. Type of system: ❑ Cesspool(s) ❑ ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste
6: System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G
kHaule Lowell Waste Water
.Sign a Crate
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