HomeMy WebLinkAboutSeptic Pumping Slip - 94 SHERWOOD DRIVE 10/16/2017the local Board of Health or other approving authority.
Commonwealth of Massachusetts
City/Town of
ECE
System Pumping. Record
Form 4
DEP has provided this form -for ussby local Boards Of Health. Other forMutvv-mH (aly;:)(); -1:sle'Ndt,)':111;<;th
information must be substantially the same as that provided here. Before thulL";Pfo'Rrnilik checkwith your
local Board of Health to determine the form they use. The System Pumping Record. must be submitted to
. A. Facility Information
1. System Location: Left / Right front of house, 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
Address
City/Town
2'. System Owner:
--)
State Zip Code
Name
Address (if different from location)
City/Town
Stat •
17 3—qc)
Telephone Number
B. Pumping Record,
1. Date of Pumping
Date 2. Quantity Pumped: Gallons
3. Type systern' D Cesspool(s) erg--ctic--Tank 0 Tight Tank
0 Other (describe):
4. Effluent Tee Filter present? 0 Yes If yes, was it cleaned? 0 Yes rl No,
Condition of Byste
6: System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Location e contentswere disposed:
Lowell Waste Water
Sign e. Haul
F5821
Vehicle License Number
t5form4.doc 06/03
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