HomeMy WebLinkAboutSeptic Pumping Slip - 144 CRICKET LANE 9/30/2016 Commonwealth of Massaohusefts
4
CiWTown of �
System Pumping-Record OC( '
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 Locati re
y q Ligh nt of hoe igh#rear of house, Left/right side of house, Left/
Right of boifdlhi Left/Rion u Left/Right rear of building, Under deck
g 9y g J, g g,
Address 1 r
C r�
City/rown State Zip Cade
2. System Owner.
Name'
Address(if different from location)
City/Town _ State, r z i5l
F
Telephone Number
i
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons —"
3. Type-of s ystem ❑ Cesspool(s) ,—,-polce Tank
❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ^o if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6: System Pumped By:
Nell.Bateson " F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatio Are contents-were disposed:
S". }
Lowell Waste Water
LY
fOA
. �
SignAt4e I Hauie Date
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