HomeMy WebLinkAboutSeptic Pumping Slip - 143 DUNCAN DRIVE 8/9/2016 Commonwealth of Massachusetts RECEIVED
= u City/Town of A UG' 1 2 01 fi
S�,/' tem Pu[1 ping.Record "I' OF*140RI1i A11��OVE HEALTH 1.61/RIMEM'
Form 4
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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 house,( e�Righ ear_ofi house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
city[rown State Zip Code
2. System Owner:
A�I A( C-1,0
Name'
Address(if different from location)
cityrrown ' Stattte__ Zip Code ;
t �tJ Sj q
Telephone Number r`
1
.B. Pumping JRgcord
1. Date of Pumping Date 2. �antity Pumped: cailon��-�� �
3. Type-of system: ❑ Cesspool(s) ®" Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If yes, was it cleaned? Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
! Company
7. Location where contents-were disposed:
GLLSQ Lowell Waste Water
Sign a Houle Date
t5forrn4.doc•06/03 System Pumping Record•Page 1 of 1