HomeMy WebLinkAboutSeptic Pumping Slip - 49 PADDOCK LANE 11/7/2016 Commonwealth of Massachusetts
City/Town of . RECEIVED
System Pumping.Record
Form 4 NOV 15 2016
TOWN.OF NUK a H rIN) AVER
DEP has provided this form for use,by local Boards of Health. Other forms may�,4�p -,butthe,a
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 Inform" ation
1. System Location CJ tWgh rout w eft/Right rear of house, Left/right side of house, Left/
Right side of bul Wj, Left/Right front of building, Left/Right rear of building, Under deck
Address _
City/Town State Zip Code
2. System Owner: .
Name'
Address(if different from location)
Citylrown " Slat w Zi de
Telephone Number
m a
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons —�'
3. Type.of.system: ❑ Cesspool(s) 0 eptic Tank Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ®'_0_0�r If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System:
6. System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locat.a re contents were disposed:
G�s: Lowell Waste Water
4KO- A
Sign a Hr3ule Date
t5forrn4.doc•06/03 System Pumping Record•Page 1 of 1