HomeMy WebLinkAboutSeptic Pumping Slip - 54 OLD CART WAY 10/10/2016 Commonwealth of Massachusetts RECEIVED
City/Town of ,
S stem Pumping.Record
Form 4
DEP has provided this form for use=by local Boards of Health. Other forms may'be'used, but the
lnformation 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 housa,,_Ce f rightCsid �Q h u Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
f.
cityfrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
cityfrown ' State Zip Code
<° l l ;
Telephone Number
i
.B. Pumping Rgicord
Date Gallons
1. Date of Pumping 2 uantity Pumped: �—�— —
r
3. Type-of system. ❑ Cesspool(s) Q Septic Tank ❑ Tight Tank
[] Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle license Number
Bateson Enterprises Ina
Company
7. Locafron_where contents were disposed:
LS- Lowell Waste Water
Signitu a cf Haule Date
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