HomeMy WebLinkAboutSeptic Pumping Slip - 67 CRICKET LANE 12/4/2017 _ Commonwealth of Massachusetts
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CIWTown of .
System Pumping.Record
Form 4
D -P has provided this form far use-by local Boards of Health. Other form's may�be'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 forrh 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 Location: Left/Right front of Hous , e r tear of hawse, Left/right side of house, Left1
Right side of building, Left I Right front of bu g, Left I Right rear of building, Under deck
Address C
Citylrown state Zip Code
2. System Owner.
Lo
Name'
Address(if different from location)
Cityrrown ' State- Zip Code
4. -
Telephone Humber
' a i
i
.B. humping kecord
L C
7. ®ate of PumpingDate 2 uantity 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:
o Vv\ e
6: System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
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E
--.. ..._
Bateson Enter Ina
Company
7. Location where contents-were disposed:
G-L&P Lowell Waste Water
A, I�SA
SignAt4e 9t Haute Elate
t5form4.doc-06103 System pumping Record•page I of 1