HomeMy WebLinkAboutSeptic Pumping Slip - 164 MILL ROAD 10/5/2016 Commonwealth of Massachusetts
City/Town of .
SOtem Pumping-Record llcw 1, Ot..
Form 4c�.. ,i
DEP has provided this form for use-by local Boards of Health. Other forms maybe'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: Loft/Right front of house, Left/Right rear of hous 0- ight�qqfhous Left Righ t side of building, Left/Right front of building, Left/Right rear cif building, Un
Address <
City/rovwn State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State rZip Code ;
t
Telephone Number .
.B. Pgmping ttacord
1. Date of Pumping Date 2. Quantity Pumped: Gallons r
3. Type-of system: F1 Cesspool(s) eptiC Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes la✓^�r If yes,was it cleaned? ❑ Yes ❑ No,
' 6. Condition of System:
6; System Pumped By: .
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Loca ' t • ere contents were disposed:
G L S: Lowell Waste Water
Sign a Hauletj Cate
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