HomeMy WebLinkAboutSeptic Pumping Slip - 65 CEDAR LANE 10/17/2016 Commonwealth of Massachusetts
= City/Town of
System Pumping-Record
r Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe bsed, but the
information-must be substantially the same as that provided here. Before using Ahis form, '
heck with your
local Board of Health to determine the farm 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 hour e lgh�e of house Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear o building, Under deck
Address
w
Clty/Town State Zip Code
2. System Owner. r
Name"
Address(if different from location)
Cityfrown State
Code
t
Telephone Number
B. Pumping JRpcord
7-4—=o
1, Date of Pumping gate 2. Quantity Pumped: Gallons
3. Type-of s stem`:
yp y. ❑ Cesspool(s) eptic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ej -,No if yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
"
6. System Pumped By:
Neil.Batesan ' F5821
Name Vehicle License Number
Meson Enterprises Inc'
Company
7. Locati ere contents-were disposed:
_L S. Lowell Waste Water
SignAtu Fe I HauleV Date r
t5form4.doo•06/03 System Pumping Record•Page 1 of 1