HomeMy WebLinkAboutSeptic Pumping Slip - 68 CRICKET LANE 11/17/2016 Commonwealth of Massachusetts
City/Town of
ECEIVED
System Pumping-Record ( 8 U1
Form 4 pWy ry y y y ( )�
y- • 41�P'MN8`4V 4�iLJR 116 P'vMV{..OVER,
DEP has provided this form for use-by local Boards of Health. other forms malt in,,Wike
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 I Right'rear of house, Left 9 t ht side of houses Left/
Right side of building, Left I Right front of buildin Left/Right rear of buildin , ner de
Y g
9 9 Ck- ..
Address
City/Town State Zip Code
2, System Owner
) ;may
Name'
Address(if different from location)
Citylrown ' state Z'jp_Code ;
Telephone Number t
i
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ®,..$eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Ye,,s �1 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, Location wherecontents were disposed:
G L S. Lowell Waste Water
❑
sign a
Date
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