HomeMy WebLinkAboutSeptic Pumping Slip - 41 CROSSBOW LANE 8/26/2016 : Commonwealth of Massachusetts
City/Town of ° �1���� ��
System Pumping-Record 'A r . 1, Q
Form 4 TOWN OF 101,,TH i��DO F�
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DEP has provided this farm 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#f/"Rig%' &T hous�,� eft/right side of house, Left/
Right side of building, Left/Right fron#of buil�Lefrear of building, Under deck
Address
CityCrown State Zip Code
2. System owner.
Name.
Address(if different from location)
City/Town State Zip Code ;
�-- Ci tee
y Telephone Number r
B. Pumping JRpcord ..
1. Date of Pumping Date 2. Quantity Pumped: Gallons y
3. Type-of system: ❑ Cesspool(s) e`ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep 0—fgo 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. Lo here contents were disposed:
G L S Lowell Waste Water
Sign a Da te
t5form4.doc•06/03 System Pumping Record•Page 1 of 1