HomeMy WebLinkAboutSeptic Pumping Slip - 71 WILLOW RIDGE ROAD 11/21/2017 Commonweedth of Massaohuseft5
Citj ffown of
° SY'4tem Pumping-Record I'OWN OF NORTH A :V
Form 4
V+
1
DEP has provided this form for use-by local Boards of,Health. Other forms may be'used, but the
information,must be substantially the same as that provided here. Before using.this form, '
heck with your
local Board of Health to determine the forrrl they use.The;System Pumping Record must be submitted to
the local Board of Health or other approving authority. 1
A. Facility. Information
I. System Location: a Righ frbrit hohouse eft/Right rear of house, Left./right side of house, Left
Right side of buil eft/R�'1`"'i'rt�fr+�n oTtaulldlri , Left/Right rear of building, Under deck
g g g g g,
Address
Cityrrown - State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town • State-
Telephone
tate"Telephone Number + "4
f
` r
. Pumping.,Ripcord �.
1. Date of Pumping sate 2. Quantity Pumped:
Gallons
3. Type-of system: El Cesspool(s) eptic Tank El Tight Tank =
El Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes,was it cleaned? ❑ Yes ® No,
5. Condition of System: _
6. System Pumped By:
Neil,Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati nh re contents-were disposed:
.L S: Lowell Waste Water
"7
signAtu e HaulerU Date
t5form4.doc+08103 System Pumping Record+page 1 of 1
