HomeMy WebLinkAboutSeptic Pumping Slip - 75 STERLING LANE 5/15/2017Co onwealth of Massachusetts •
City/Town of
701(
ystern ec • r• Mi\3
I‘CTIEALII DEPPaT MEI
Fo 4
DEP has provided this form. for usaby local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using.this forrn, 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 Locatio L Rig
Left / Right rear of house, Left / right side of house, Left /
Right side of b g, Left / Rit ?tRf building, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
Address (if different from location)
City/Town
TelephoneNumber
PLIM
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1
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
. Type of system 0 Cesspool(s)
eptic Tank Tight Tank
Other (describe):
4. Effluent Tee Filter present? 0 Yes ra-f If yes, was it cleaned? 0 Yes 0 No,
. Condition of System:
LL
6. System Pumped By:
Neil Bates -oh_
' Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G. S. Lowell Waste Water
F5821
Vehicle Lice e Number
t5form4.doc. 08/03 System Pumping Record Page 1 of 1