HomeMy WebLinkAboutSeptic Pumping Slip - 100 NORTH RAMP ROAD 12/9/2017 : Commonwealth of Massachusetts
z Cityffown of .
SYW m Pumping-Record
Form 4
DEP has provided this form for rase=by local Boards of Health. Other forms may be bsed, but the
information'must be substantially the same as that provided Isere. Before using.this form,check with your
focal Board of Health to determine the forrh they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
p
A. Facility InforMation
1. System Location: Left/Right front of house, Leff I Right e r of house Left/right side of house, Left/
Right side of building, Left I Right front of buiidirig, Left Ri h rear of build' Under deck
Address
Cityfrawn State Zip-Code
2. System Owner.
Name'
Address(if different from location)
cityfrown State- Zip Code
Telephone Number Fwd
t
B. Pumping Record .
7. Date of Pumping �to Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
�] Other(describe):
4. Effluent Tee Filter present'? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
6. System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Ehterprises lnc'
Company
7. Locationhw a contents-were disposed:
GL Lowelf Waste Water I
y
Sign a Haul Date
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