HomeMy WebLinkAboutSeptic Pumping Slip - 25 SUNSET ROCK ROAD 4/3/2018 Commonwealthf Massachusetts
Form, 4 JiMili DEPAPMENT
DEP has provided this ford for use-by local Boards cif Health. Other forms may be'used,but the
lnformation-must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use. The;Systrn Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. FaciRty, Inform' sition
_
1. System Location: Left/Right front of Mouse, Le lghf rear , Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear(if building, Under deck
. Address
City/Town State zip code
2. System Owner:
Name
Address Of different from location)
City/Town • '. State �•, r �� Zip Cod ,
'telephone plumber
r
a rvl n r .
1. bate of Pumping Date 2. Quantity Pumped: ---�
Gallons ,
I Type-of system: Cesspool(s) eptic Tank (l Tight Tank
Other(describe):
4. Effluent Tee Filter present? ❑ Yep No if yes, was it cleaned? ® Yes ❑ No,
' 5. Condition of System:
6: System pumped By:
Nell.Bateson - F5821
Name Vehicle License Dumber
_Bateson Enterprises Ina
Company
7. Loca" contents-were disposed:
L S 7Lowell Waste Water
E
Slgn a Flhul Date
tftrrn4.doom 06/03 System Pumping Record a Page 9 of 1