HomeMy WebLinkAboutSeptic Pumping Slip - 62 BANNAN DRIVE 11/21/2017 Commonwealth of Massachusetts CV r
CI Town of
Cvi-I
System P'-umping.Record
Form 4
DEP has provided this form for use�by local Boards of Health. Other form's may be'used, but the
a
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 System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility InforMation -
1. System Location: Left/Right front of house, Left]Right rear of house, Left/r�lgh ide of hous , Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address t �
City/row n State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/rown • $late yrf '
Y p)Co e
Y
Telephone Number 1
. Pumping Record
�. .. _w._ 7 `�J
1. Cate of Pumping — 2. Quantity Pumped:
Gallons
3. Type-of system: ® Cesspool(s) ] Ts ank
El Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes, was it cleaned? ❑ Yes E] No,
5. Condition of System•
Vc-�,f �6cu ck
6; System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locf�toza ;r er. contents were disposed:
G L Lowell Waste Water
WeRa Cate f
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