HomeMy WebLinkAboutSeptic Pumping Slip - 44 CRICKET LANE 9/28/2016 uV ,f
Commonwealth of Massachusetts
City/Town of
System Pumping-Record
Farm 4
Vi
DEP has provided this form for use.by local Boards of Health. Other form's may be'used, but the
informatlon'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, Left/right side of house, Left/
Right side of building, Left I Right front of building, Left I Right rear of building, Under deck
IN A
Address
City/Town (� State Zip Code
2: System Owner. , J
Name'
Address(if different from location)
Cityrrown ' State M- Cade
ffi Telephone Number �
i
.B. Pumping kacord
1. Date of Pumping bate 2. Quantity Pumped:
Gallons
3. Type-of s stem: `
Yp Y. ❑ Cesspool(s) � Septic Tank El Tank
❑ Other(describe):
r
4. Effluent Tee Filter present? Y_ ❑ No If yes, was it cleaned? [B ❑ No,
ell-
5. Condition of System: ` �.,
�°' _ \,
�l
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lo re contents were disposed:
, G_ S. Lowell Waste Water
SignAtufe I Haule pate
t5form4.doc-06/03 System Pumping Record*Page 1 of 1