HomeMy WebLinkAboutSeptic Pumping Slip - 30 SUGARCANE LANE 11/8/2016 . .`�, Commonwealth of Massachusetts RECEIVED City/Town of . System Pumping.Record s Form 4 "TOWN OF NUK�H F4&)OVER " HEAL"rH DEi'"ARI"ME:N DEP has provided this form for use-by focal 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 Location: Left Right front of houser"`Left/Right rear of house, Left/right side of house Left/ Right side of building, Left/R gbt fror► of bufldfrig, Left/Right rear of building, Under deck Address C-) _ City/Town State Zip Cone 2. System Owner. ( ' NAVY � Name ; Address(if different from location) City/d own ' Stater Zip Code ; Telephone Number , i B. Pumping ttecord 1. Bate of Pumping - Quantity Pumped: C�C> Date Gallons 3. Type-of.system. ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No, 5. Condition of System: f ' cma I If 0 t 6. System Pumped By: Neil.Bates©n ' F5821 Name Vehicle License Number Bateson Enterprises Inc, Company 7. Locayon-whe a contents were disposed: 4Signe Lowell Waste Water HiulerU Date t6form4.doc•06/03 System Pumping Record•Page 1 of 1