HomeMy WebLinkAboutSeptic Pumping Slip - 123 MARIAN DRIVE 10/6/2016 Commonwealth of Massachusetts R E IV h^ °
CRY/Town of OC � I
S'�/Stem P��roping-lRecord rOVVN���u� r,��n�,fl r�I �����rE��R
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/ r ht rear of house Left/right side of house, Left/
Right side of building, Left/Right front of building, Left ig ° air 6 building, Under deck
Address "�
City/Town State - Zip Code
2. System Owner.
C-2- `C ��: � '
Name'
Address(if different from location)
city/rown ' State _Zip e
CSC
Telephone Number -a.
.B. Pumping Record
66:
cam, l
1. Date of Pumping date 2. Quantity Pumped: --�
�.--� Gallons
Q
3. Type-of system: ❑ Cesspool(s) –3 ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? es ❑ No,
' S. Condition of System:
6: System Pumped By:
Neil.Batesbn - F5821
Name Vehicle License Number
Bateson Enterprises inc
Company
7. Locatio �u ere contents were diseased:
G,L S: Lowell Waste Water
' F
Sign a Haute Date
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