HomeMy WebLinkAboutSeptic Pumping Slip - 25 HOLLOW TREE LANE 10/11/2016 . ,, Commonwealth of Massachusetts
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System P"um En ' -Record
Form 4 p g1 .�r�r�rr�
DEP has provided this for m for use by fecal 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 Locatio G IgIV-1;.a f tious Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of buildirg, Left/Right rear of building, Under deck
Address tj&
Ciw/Town State Zip Code
2. System Owner.
Name"
Address(if different from location)
Cityfrown ' State l C y Zio Code
a Telephone Number �!
.B. Pumping Record
1. Date of Pumping date 2. Quantity Pumped: Gallons`
3. Type,of system: ❑ Cesspool(s) ❑ . IIc Tank ❑ Tight Tank
[] Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: .- W
Gib,.,, �-�...
t�
6: System Pumped By:
Neil.Bateson " F5821
Name Vehicle License Number
Meson Enterprises Inc
Company
7.iSigne w re...contents"were disposed:
. Lowell waste Water Haute Date
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