HomeMy WebLinkAboutSeptic Pumping Slip - 60 DEER MEADOW ROAD 6/13/2016 Commonwealth f Massachusetts
i wn of RECEIVED
YS
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Form 4
DEP has provided this form for use=by local Boards of Health. Other foh y 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 foram they use.The;System Pumping Record must be submitted to
the local Board of Health or other approving authority.
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A. Facility. 1 fir anti
1. System Location: Left/Right front of house,of building,/ Left/rear rear house,build grigh sk a of house, Left/
y Right ar deck
Right side of building, Left/Right front 9,
Address
"�- ..� Zip Code..
Gity/rown State P
2. System Owner
Name
Address(if different from location)
Z
city/Town State � q
Telephone Number
i
B. Pumping Record
1. Date of Pumping Date
2. Quantity Pumped: Gallons y
3. Type•of system: ❑ Cesspool(s) ❑ ptic Tank ® Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ 'o If yes, was it cleaned? ® Yes ® No,
5 Condition of System: 4 C -,Ff* _..._
.. :.
6; System Pumped By:
Neil.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo flogy�her contents were disposed:
G L S: Lowell Waste Water
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;igIeWe-
-75 Date
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