HomeMy WebLinkAboutSeptic Pumping Slip - 60 LONG PASTURE ROAD 11/4/2016 Commonwealth of Massachusetts
4
_ . City/Town of .
RECEIVED
System Pumping.Record
Record
Form 4 "a Z01 b
DEP has provided this form for use-by local Boards of Health. Other forrns7fmy"ba hfsed, bui t R
information must be substantially the same as that provided here. Before usir Ahis°form, Chad 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 house, Left J Right rear of hour Le • ri fe eof hots Left/
Right side of building, Left/Right front of building, left/Right rear of building, Un er ec
Address
Cityl'rown State Zip Code
2. System Owner.
Name'
Address(If different from location)
City[Town State Zip code
f Telephone Number f '
.B. Pumping Record
1. Date of Pumping date 2. Quantity Pumped: Gallons y
3. Type-of system. F-1 Cesspool(s) O-S is Tank ❑ Tight Tank ,.
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of,Syste
6: System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loco where
contents-were disposed:
C L Lowell Waste Water
Sign a Houle Date
t5farrn4.doc•06/03 System Pumping Record•Page 1 of 1