HomeMy WebLinkAboutSeptic Pumping Slip - 130 HAY MEADOW ROAD 4/27/2017 Commonwealth
City/Town of RECEIVED
Form 4
DEP has provided this forms far use-by local Swards 6f Health. Other f 4v'" y' 'i II, but the
information must be substantially the tame as that provided here. Before using.t'his farm.,check with your
local ward of Health to determine the forms they use.The System Pumping Record rust be subrnitte�d tc)
the local ward of Health or other approving authority.
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m FacMty Information
1. System Location: Left/Dight front of Mouse, Left/Right rear of house, Left/rig�da4j use, LeftRight side of building, Left/Right front of building, Left/Dight rear®f building,
Address
,�.
City/rown � State Zip Cabe
2: system Ower:
Name' UU
Address(if different from location)
f JCS µ:-QW Q -
City/Town, tett- Zip Cade
•
Telephone Number
Q
,I
1. Date of PumpingCate . Ousntily F'urnped:
Gallons
. 'hype-of system: El cesspool(s) 0--Septic;"lank El Tight Tank
E] Other(describe):
4.. Effluent"fee Filter present.? El Yep 13, No if yes,was it cleaned? Yes No,
S. Condition of am: �
6. System Pumped By.
Nell.Sates-on P5821
Name Vehicle License slumber
Sate�on Er►terprises Irtc•
Company
7. Locatio, here contents-were disposed:
!Signn
PHIawle Lowell Waste Water
. l
ante
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