HomeMy WebLinkAboutSeptic Pumping Slip - 546 SHARPNERS POND ROAD 10/17/2016 Commonwealth of Massachusetts
City/Town of
System Pumping.Record
>>�r,
Form 4
DEP has provided this farm for um by local Boards of Health. Other forms maybe used, blot 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
I. System Location: Left l Right front of Mouse, Left/Right rear of house, Left ht si' house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
city/rown State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/rown ' Stat Zip Code
7 w-� -S
Telephone Number
. 1
._ a
.B. Pumping Record `
to - (` . .
1. Date of Pumping sate 2. Quantity Pumped:
Gallons P
3. Type-of,system. ❑ Cesspool(s) ® eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition of System:
PO r1jL
6: System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. LoCation here contents were disposed:
aL S: Lowell waste Water
sign a HauleV Date
t5form4.doc•08/03 System Pumping Record•Page 1 of 1