HomeMy WebLinkAboutSeptic Pumping Slip - 60 SUNSET ROCK ROAD 8/30/2016 Commonwealth of Massachusetts rl °��°E E
City/Town of
S stem Pumping.Record
� . Form 4 HEAI"f1�n�.:D%R PALI F
y4
DEP has provided this form for use-by local Boards of Health. Other form's maybe*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 clht front of ' s , Leff/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
mylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town ' State /�y¢J Z
0 � p
Telephone Number
a
.B. Pumping Record
1. Date of Pumping sate 2. Quantity Pumped:
. Gallons
3. Type-of system. ❑ Cesspool(s) EYgeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 9-1qo—V 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. Locati ere contents were disposed:
C S: Lowell Waste Water
J d
Sign a 9t Haule Date
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