HomeMy WebLinkAboutSeptic Pumping Slip - 84 SUGARCANE LANE 9/15/2016 Commonwealth of Massachusetts
City/Town of '� w°°
System Pumping-Record
Form 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 Q er Left/Right rear of house, Left/right side of house, Left f
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
CiWTown `X State Zip Code
2. System Owner.
Name`
Address(if different from location)
Cityfrown Skate Zip Code
Telephone Number r .
F.
.B. Pumping.Rpcord
1. Date of Pumping ate g 2. Quantity Pumped: ---P~°�
• Lallans
3. Type-of system'. ❑ Cesspool(s) ® sunk ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 014o" If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Sy tem:
6. System Pumped By:
Nell.Batesbn - F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
G L S Lowell Waste Water
Sign a —HauleV Date
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