HomeMy WebLinkAboutSeptic Pumping Slip - 50 LOST POND LANE 8/23/2017 Commonwealth of Massachusetts RECENED
City/Town of
system Pumping Record10,WMADOY
Form 4
w. l
DEP has provided this form for use-by local Boards of Health. other forms maybe*used, but the
Information,must be substantially the same as that provided here. Before using.this form,check with your
iocal Board of Health to determine the foriin they use. The System Pumping Record must be,submitted.to
the local Board of Health or other approving authority. j
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A. Facility. tnforMation
I. System Location: Left/Right front of house, Left I Right rear of house, Left/ l�"�f side of hour Left/
Right side of building, Left/Right front of building, Left I Right rear of building, Under deck
Address
Citylrown State - Zip Cade
2. System owner.
Name`
Address(if different from location)
Cityliawn ' State/ � CY J- e ;
t 'telephone plumber !,
. Pumping Record
9, Gate of Pumping Date 2. Quantity Pumped: Gallons
3. Type•of system: ® Cesspool(s) eptic Tank ® Tight Tank
® other(describe):
4. Effluent Tee Filter present? El Ye, o If yes, was it cleaned? ® Yes ❑ No,
5. Condition of Sy to
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License plumber
Bateson Enterprises Inc-
Company
7. Lowh contents-were disposed:
C L S: re Lowell Waste Water
—Vr I IQ�l V2) t
f
signAture I Hauleqj Date
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