HomeMy WebLinkAboutSeptic Pumping Slip - 42 SPRING HILL ROAD 12/13/2016 Commonwealth Massachuseffs
C i s n of
� Form.
TOWN 0- i�/.?d�t'��HAR��'U/k��.r�i��
DEP has provided this fortri for use-by local Swards of Health. Other farms M1''ay u e ` &the
information must be substantially the tame as that provided here. Before using.this farm,check with your
local Board of Health to determine the forth they use.The System Pumping Record must be submitted t®
the local Board of Health or other approving authority.
A. Facility Inf rM ti n
I. System Location: Loft/Right front of hous ' e ; Righ����r`of house, Left/right side of house, Left f
+: Right side of building, Leaf/Right front of b ' g, Left/Right rear of building, Under deck
Address
City/Town State Tip Cotle
2. System Owner:
Name'
Address(if different from location)
City/1'own State
t; � "`°�' l�Z da
"telephone Number
B. i
in r
1. Date of Pumping Cate 2. Quantity Pumped: Gallons
. Type-of system: El Cesspool(s) eptic Wank Tight Tank
Other(describe):
4. Effluent Tee Filter present? a No If yes, was it cleaned? es Now
5. Condition M, t• .
6: System Pumped Sy:
Nell.Eateson F5821
Name Vehicle License Number
Eateson Enterprises Ina
Company
7. La tion r-here contents were disposed:
�L S Ty Lowell Waste Water /
Sign a Houle Crate
t5form4.doe-06/03 System Pumping Record®Page I of 7