HomeMy WebLinkAboutSeptic Pumping Slip - 116 CHRISTIAN WAY 11/2/2016 Cornmonweaith of Massachusetts
_ City/Town of .
S
RECEIVED
ystem Pumping-Record
Form 4 NOV 15 zMb
DEP has provide this form for use=by local Boards of Health. Other form's r;� H ANUOVER
information must be substantially the same as that provided here. Before usiniis 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
I. System Location: Left/Right front of House, Left RI rear of house a Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
CityCrown S to Zip Cade
2: System Owner.
c
Name
Address(if different from location)
citylrown ` Stater Zip Code
t Telephone Number '
;.
.B. Pumping !Record
1. Date of Pumping pate 2. Quantity Pumped: Gallons r"`
3. Type-of s stem:
Yp Y. ❑ Cesspools) eptic Tank [] Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes lIo If yes, was it cleaned? ❑ Yes [I No
' 6. Condition of System-�u`
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
B_ateson Enterprises Ina
Company
7. Locafirp hJ, e contents were disposed:
L S Lowell Waste Water
LAMM -a (c,
Sign a Houle Date F
t5form4.doc.-06/03 System Pumping Record*Page 1 of 1