HomeMy WebLinkAboutSeptic Pumping Slip - 10 DUNCAN DRIVE 11/11/2016 Commonwealth of Massachusetts RECEIVED
City/Town of . .
System Pumping.Record
W.
Form 4 HEALTH DEPARTMF NT
DEP has provided this form far use-by local Boards of Health. Other forms may be bled, 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 Informlation
1. System Location: Left/Right front of hious ight rear of house, Left/sight side of hour, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under ec
Address
city/Town _ State Zip Code
2. System Owner.
Name
Address(if different from location)
CitylTown ' S#ate 1p Code
Telephone Number
i
.B. Pumping Kecord
1. Date of Pumping Date 2 �Qu6ntl °Pumped:
Gallons `—
3. Type-of.system`: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. system Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Loca`che a contents were disposed:
G.L
AD Lowell Waste Water
4SIgnitufe VJ-Ha-ule Date
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