HomeMy WebLinkAboutSeptic Pumping Slip - 83 LOST POND LANE 6/5/2017 Commonwealth of Massachusefts RECEIVED
CWTown of JUN 13 ?017
ffi
s0tem Pumping.
Form 4 5
dL ILTI•i DEPARTMENT
DEP has provided this form for use-by local Boards 'of Health. Other forts may be'used, but the
informa, tion•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. FacWty Intoe ti
I. System Location: Left/Right front of house, Left/Right rear of house, Left/right side pf house, Left
Right side of building, Left I Right front of building, Left I Right rear of building, tinder deck
Address -.. .m
ic,�( ..
C"rtylrovvn state Zip Coyle
2. System Owner:
Name`
Address(if different from location)
cityfrown - tetet/
f 'telephone Number �
l
® Puenping
1. Date of Pumping ole 2. Quintlty Pumped:
Gallons "
3. Type-of system`: Cesspool(s) eptic Tank [] Tight Tank
Other(describe):
4. Effluent Tee Filter present? Ej Yep c If yes, was it cleaned? E Yes Ej No,
6. Condition of Sys m: ,
Pv c4j ____...
w
6. System Pumped By:
Nell.Bat bn - P582.1
Dame Vehicle License Number
Bateson Enterprises Inc,
Company
7. Lo ti wv er contents were disposed:
L S'. Lowell Waste Water
' d
Sign a W,u1e bate
t5fbrm4.doc9 06/03 system Pumping Record Bags I of 9