HomeMy WebLinkAboutSeptic Pumping Slip - 141 STONECLEAVE ROAD 6/29/2017Commonwealth of Massachusetts
City/Town of .
System Pumping. Record
Form 4
DEP has provided this form for use by local Boards of Health. Other forms rti • • TuENT
NtraVtEhRe
• . TO
information' 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 ystern Pumping Record must be submitted to
the local Board of Health or other approving authority.
ECEIVED
JUL 2011
A. Facility Information
1. System Location: Left / Right front of house, Leftfight rear of houtA Left / right side of house, Left /
Right side of building, Left / Right faint of buildirig, Lift-TIg-ht rear of building, Under deck
Address
City/Town
2. System Owner:
cl--ovve
Zip Code
Narbe.
Address (if different from location)
City/Town'
B. Pumping Record
1. Date of Pumping
3. Typeof system':
Other (describe):
4. Effluent Tee Filter present? 0 Yes
" 5. Condition of System:
6.' System Pumped By:
Neil Bateton
' Name
Bateson Enterprises Inc
Company
7. LocationWhere contents were disposed:
GL Lowell Waste Water
State. Zip Code
t7e1
Telephone umber
uantity Pumped:
Date Gallons
Cesspool(s) Septic Tank El Tight Tank
If yes, was it cleaned? D Yes D No,
F5821
Vehicle License Number
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