HomeMy WebLinkAboutSeptic Pumping Slip - 155 CHRISTIAN WAY 8/11/2016 Commonwealth of Massachusetts
RECEIVED
City/Town of .
System Pumping. Record
�`... Form 4 I'M OF NOR[ IANDO"VL�R
HEALTH C)EPAMMi::€T
DEP has provided this form far use-by local Boards of Health. Other forms may 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: LekrKl t front of douse; Left/Right rear of house, Left/right side of house, Left
Right side of building, Left ight front of building, Left/Right rear of building, tinder deck
. Address
Cityfrown stalk Zip Code
2. System Owner: f�
Name*
Address(if different from location)
Ci#ylrown • State- f� t ,�.. J�de ;
Telephone Number
i
.B. Pumping Record
C
. t Cf
1. Date of Pumping 2. Quantity Pumped:
. Date Gallons
3. Type-of system: ❑ Cesspooi(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yeis No if yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System•
6. System Pumped By:
Neil.Bateson - F6821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo ti w er eantents were disposed:
C L S: Lowell Waste Water
. f
Sign a Haula Date
t5form4.doo-06/03 System Pumping Record•Page 1 of 1