HomeMy WebLinkAboutSeptic Pumping Slip - 78 VEST WAY 10/20/2016 : Commonwealth Of Massachusetts
M City/Town of
. ,gym
System Pumping.Record
Form 4
1, �O t�j
dEP has provided this form for use.by focal Boards of Health. Other forms may�b 'irsed� but the f"
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
I. Left/ house,
se), Left/Ri ht side of building, Left Right font of building, Left/Right rear of ildin building,
deck
Address p {
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown ` State zin( `7_ ' �_ ll e
`telephone Number
j
i
B. Pumping R acord
1. Date of Pumping Date 2. Quantity Pumped:
Gallons `
,..w
3. Type-of s y stem: ❑ Cesspool(s) [ " e p ti c Tank ❑ Tight Tank • }
❑ Other(describe): -�
4. Effluent Tee Filter present? ❑ Yep (�i ,+40 if yes, was it cleaned? ❑ Yes
. ❑ Na,
' S. Condition of.System:
6: System Pumped By.
Nell.Bateson • F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo ere contents were disposed:
G L S: Lowell Waste Water
Sign a Houle Date F
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