HomeMy WebLinkAboutSeptic Pumping Slip - 124 STONECLEAVE ROAD 9/13/2016 Commonwealth of Massachusetts � ��� 'ro ` ����
City/Town of
System Pumping. Record � ��" ��� ��;� �� 1� )W R
Form 4 E�04lkRWEWT
4�
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 l Right front of houskl;10 Righ a of hour, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
CiivTown State Zip Code
2. System Owner.
Name'
Address(if different from location)
citylrown ' Stat Zin Cade
Telephone Number
.B. Pumping Record
1. Date of Pumping Date _ 2 O ntity Pumped: calms Y—
3. Type-of system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes 0 No,
5. Condition of System: _ v _ c4z, �,__
6. System Pumped By:
Nell.Bateson " F5821
Name Vehicle License Number
Bateson Enterprises Inc"
Company
7. Locafi hire contents were disposed:
Lowell Waste Water
SignAtu,te qf Houle Date
t5f6rm4.doo-06/03 System Pumping Record•Page 1 of 1