HomeMy WebLinkAboutSeptic Pumping Slip - 32 DEER MEADOW ROAD 10/14/2016 : Commonwealth of Massachusetts
QWTown of
System Pumping.Record
a
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
locail 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 hou , Le ig a of h �; Left/right side of house, Left/
Right side of building, Left/Right front of bur ding, Left/ lg rear of building, Under deck
Address R; flwx�llj
` 1z
City/Town state Zip Code
2. System Owner.
Name
Address(if different from location)
CityfTawn State„, L6. Zi 1 „.Y
f� w
F 'telephone Number r'`a
' F
.B. Pumping Record
1, Date of Pumping 2. Quantity Pumped: '
Date Gallons y
3. Type'of system`: ❑ Cesspool(s) [9119eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ Na
' 5. Condition of System,
6: System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. L�Catti on e ere contents were disposed:
L S'. Lowell Waste Water p
Sign a l-laule Date
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