HomeMy WebLinkAboutSeptic Pumping Slip - 51 LONG PASTURE ROAD 5/1/2017 Commonwelalth of MassachuseffsRECEIVED
n of
Form 4
as bLl.p 1F' " hYf-W
7,
DEP has provided this form for use-by local Boards of Health. Other fauns may be'used,but the
information`roust be substantially the tame as that provided here. Before using.this form,check with your
la 'i Board of Wealth to determine the form they use.The$ystem Pumping Record roust be submitted t
the Foal Board of Wealth or other approving authority.
A. Facfloty. Inform
1. System Location: L �n haus_,, Left I Wight rear of house, Left/right side of house, Left/
Right side of building, Left I Right front of building, Left/Right rear of building, Under deck
Address
City/•TaWState Zip Code
2; System Owner:
Dame'
Address(if different from location)
CityrTown - State Zip Code
Telephone plumber
® I ' "
Ll
1. date of Pumping r `' r �2uanl ity Pumped: 0
bare Gallons
. Type-of system: El Cesspool(s) peptic Tank El Tight'Tank
Other(describe): - ----- _ --�w
4. Effluent Tee Filter present? Yep No If yes,was it cleaned? Yes No,
5. Condition of.System:
6. System Pumped By:
Nell.Betesbn ` F6821
Name vehicle License Number
�ateon �rtiterprises Inc`
Company
I. L!o�ptiowwbere contents-were disposed:
G1-S: Lowell Waste Water
Sin a Houle
2,2.- ( ,
9 Cate
l5fcrm4.dde-06/03 System Pumping Record Page t of 1