HomeMy WebLinkAboutSeptic Pumping Slip - 102 SPRING HILL ROAD 12/11/2017 Commonwealth of Massachusetts
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y° System Pumping-Record
Form 4
DEP has provided this forryi for use>by local Boards of Health. Other form's maybe'used, but the
information must be substantially the tome as that provided here. Before using.this form,check with your
Iocal 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 Inforimation
1. System Location: Left 1 Right front of house, Left 1 r h rear of hou , Left-/right side of house, Left I
Right side of building, Left 1 Right front of building, Left 1 Right rear cif building, Under deck
. Address
CfWrown oL L fstate�4 Zip Code
2. System Owner.
Name'
Address(if different from location)
C€tyTrown State ZCc g
Telephone Number yy
f
.B. Pumping record
1. Date of Pumping ole 2. Quantity Pumped: Gallons N``
8. Type-of system: ® Cesspool(s) 0,,Wptic Tank ® Tight Tank .
❑ Other(describe):
4. Effluent Tee Filter present? fes ❑ No If yes, was it cleaned? es ❑ No
6. Condition Qf System: "
6. System Pumped By:
Neil.Batesbn • F5821
Name Vehicle License Number
Bateson EhtFvrprise5 Inc,
Company
7. Lo am contents-were disposed:
G L Lowell waste Water
' F
SignA9f Hau€ Date
t5form4.doa-06/03 System Pumping Record•Page 1 of 1