HomeMy WebLinkAboutSeptic Pumping Slip - 167 DUNCAN DRIVE 7/31/2017`4
Commonwealth of Massachusetts
City/Town of .•
System Pumping. Record
Form4
DEP has provided this form for rase -by local Boards of Health. Other forms may be 'used, but the
information trust be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the forth they use. The System Pumping Record must be submitted to
the Local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left gh front of ho Left / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
v\L', .ar 1 ocA*A..-
Address A
City/rown
2. System Owner.
kA0
State Zip Code
Name
Address (if different from Location)
City/Town ' State ,�, Zip Code
9
Telephone Number
Date 2. Quantity Pumped:
3. Type -of system: ❑ Cesspool(s) ‘tic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
. B. Pumping Record
1. Date of Pumping
5. Condition of System:
Gallons i
6; System Pumped By:
Neil. Bateson •
Name
Bateson Enterprises Inc
Company
7. Location where contents -were disposed:
Lowell Waste Water
L
F5821
Vehicle License Number
Sign a Hauler{ / Date
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