HomeMy WebLinkAboutSeptic Pumping Slip - 490 SHARPNERS POND ROAD 10/17/2016 Commonwealth of Massachusetts �. t
City/Town of
System Pumping.Record
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 Locatio�``.''Le�Right ro t of hous Left/Right rear of house, Left/right side of house, Left
Right side of btlHdtfig, Left/Right front of building, Left/Right rear of building, Under deck
Address r
City/rown State Zip Code
2. System Owner:
� . V)
Name'
Address(if different from location)
Cityrrown ' Mate, Zip Code
F r
Telephone Number +—;
.B. Pumping Record
( . ca C � ..
1. Date of Pumping Date Z Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [] Yes [9-No if yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of Systenj
6. System Pumped By:
Neil.Batesbn - F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location—where contents-were disposed:
.L$CfHiaiulel..'� Lowell Waste Water
aA"
Sign Date
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