HomeMy WebLinkAboutSeptic Pumping Slip - 75 GRANVILLE LANE 9/27/2016 . Carnmonwealth of Massachusetts _ �a .� �.Jv
City/Town of ��'V�j t
Syi tern 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/Right front of house, Left/Right rear of house, Le nigh# i e o house, Left/
Right side of building, Left/Riglit front of building, Left/Right rear of building, Under
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town ` Stater, �( dip Code
Telephone Number
i
1
.B. Pumping R word
1. Date of Pumping Date �Qu6n.ty�2. i Pumped: Gallons 3. Type•of system. ❑ Cesspool(s) nk ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [9 o if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Ehterprises Inc'
Company
7. Locati n-whe a contents were disposed:
L S. Lowell Waste Water
Sign a I Haule Date
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