HomeMy WebLinkAboutSeptic Pumping Slip - 70 LOST POND LANE 11/11/2016 Commonwealth of Massachusetts RECEIVED
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City/Town of b
System P-camping.Record
Form 4 HEALTH EPARTM wcf VER
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
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 Right rear of hoiisgi Left/right side of house, Left/
Right side of building, Left/Right front of buildirg,Left/Right rear of building, Under deck
Address
r L o jPo,"k
City/Town 6f 4 state Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityfrown " State" Zip Code
Telephone Number
A`
.B. Pumping .Record
1. Date of Pumping p 2 uantity Pumped: Gallons
anst--
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:
0(k'M' �Lj we
6. System Pumped By:
Nell.Bateson F5$21
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati?,t 'whe a contents-were disposed:
C f(.S. Lowell Waste Water
i6
Sign a Haule Date
t5farm4.dov 06/03 System Pumping Record•Page 1 of 1