HomeMy WebLinkAboutSeptic Pumping Slip - 75 HAY MEADOW ROAD 12/14/2017 : Commonwealth of Massachusetts
CVTown o .
System Pumping.Record
Foam 4
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
local Board of Health to determine the forret they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Locatlonz]�ig ro tof house eft 1 Right rear of house, Left/right side of house, Left
Right side of building, Left 1 Right front of buildirig, Left 1 Right rear of building, Under deck
.
Address
Cityfrown State zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town State C ,�✓ l��Tap CgciQ �
Telephone Number
.B. Pumping Record
-� {7
9. ®ate of Pumping pate ;eptic
Quand Pumped:
Gallons
3. Type-of system: ® Cesspool(s) Tank ® Tight Tank ;
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition f stem: •�1 �J�--�� ``' � �' _ /"� .
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bates Enterprises Inc-
company mm
7. Location where contents-were disposed:
r=
^L S. Lowell Waste Water
aA Bz�z
f
Signitute fmaul Date
t5forrn4.doc•06103 System Pumping Record•Page 1 of 1