HomeMy WebLinkAboutSeptic Pumping Slip - 154 DUNCAN DRIVE 8/11/2016 Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping.Record a OF NU TH r r ra u
Form 4 �iL`XXH Di: -, RT E10'�
DEP has provided this form`for 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: Left/Right front of hoes , e Frig rea o house;)Left•/right side of house, Left/
Right side of building, Left/Right front of but trig, Left/Righ rear o building, Under deck
Address ,
t.��Cam,-t...�"�✓"�°� '{tea � � �- ��(�...�/--� '
CiiyfTown State Zip Code
2. System Owner.
C4
Name'
Address(if different from location)
City/Town Stat Z Code
Telephone Number iS
.13. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: --- -- -
` Gaitons ,r
3. Type-of system. M Cesspool(s) OSt'ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 04466—'
-tQo If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste
6. System Pumped By:
i
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Loca' h re contents were disposed:
��S'. Lowell Waste Water
Sign a 9t Haule Date
t5form4.doa 06/03 System Pumping Record•Page 1 of 1