HomeMy WebLinkAboutSeptic Pumping Slip - 50 JAY ROAD 11/28/2017 Commonwealth of Massachusetts '
CWTown of
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,System Pumping.Record
Form 4 � �.� .
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 farm they use.. The System Pumping Record must be submitted,to a
the local Board of Health or other approving authority.
A. Facility. InforMi ation
1. Sys#em Location: Left 41 G14-front f hou , Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right ront of building, Left/Right rear of building, tinder deck
Address
cityrrown State zip code
2. System Owner. t
Name
Address(if different from location)
Cilyfrown Stat e Code
F Telephone Number
i
-.
umping P.ecord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of s stem:
Y system' ❑ Cesspool(s) eank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes ® if yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition o€Syste
rje
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locati here contents-were disposed: 1
f
_L S: Lowell Waste Water
LNrc&A
Sign a Haul Cate
Morm4.doc•06/03 System Pumping Record•Page 9 of 1
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