HomeMy WebLinkAboutSeptic Pumping Slip - 7 SOUTH CROSS ROAD 12/26/2017 Commonwealth of Massachuseits
CIttj//Town of
Sy,4tern P`•umpin§.Record
Form 4 T0001 U UJr��a�
DEP has provided this form for use-by local Boards of Health. Other forms 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 farm they use. The System Pumping Record must be submitted;to
the local Board of Health or other approving authority.
' J
A. Facili•ty. InfarMation
1. System Location: Left l Right front of house, Left/Right rear of house,(Lft." Ig side a ht"u Heft/
Right side of building, Left/Right front of building, Left/Right rear of bull�dmg, Under eC
Address
City/Town State Zip Code
2. System Owner. c.A,dvA,
[Name'
Address(if different from location)
City/Town •. Stater
'telephone Number
b t
i;
Pumping Record
9. Bate of Pumping 2. Quantity Pumped:
Date Lallans ,.+
3. Type-of system: ® Cesspool(s) ' ptic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ a If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Bell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location,wi ere contents-were disposed:
G L S: Lowell Waste Water
'46 Houle Date f f
Morm4.doc•06/03 System Pumping Record.Page 1 of 1