HomeMy WebLinkAboutSeptic Pumping Slip - 50 DEER MEADOW ROAD 12/6/2017 : Commonwealth of Massachusetts
.City/Town of .
System Pumping.Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be'used,but the 3
information,must be substanfially the same as that provided here. Before using.this form,check with your
local 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.
e
A. Facility lnforMa#ion
9. System LocatioPhag.,
!Rig front of Hous , Left 1 Right rear of house, Left,/right side of house, Left
Right side of bullLeft/Right fron of building, deft/Right rear of building, Under deck
Address
citylrown state Zip Code
2: System Owner.
Name'
Address(if different from location)
Citytrown state ttom�- ee�_ =j Zi Code
Telephone Number
3 rt
• .F.
I
.B. Pumping Record
1. Date of PumpingDate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ® Tight Tank
❑ Other(describe):
4.. Effluent Tee Filter present? ® Yes 2-2-0 if yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System:
f: System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson_ Enterprises Inc
Company
7. Locati ltq)re,contents-were disposed:
G L S: Lowell Waste Water
. F
Sign a Haul Date
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