HomeMy WebLinkAboutSeptic Pumping Slip - 162 HAY MEADOW ROAD 5/22/2018 Commonwealth of Massachusetts RECEIVED
SyMem Pumping, r 'TOVV�j OF �
Form 4 1,00-1 D�ErIARTME-.NT
DEP has provided this farmfor use=by local Boards of Health. Other forms may be'used, but the
information,must be substantially the tame as that provided here. Before using.this farm,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. d • InforMation
9, System Location: Left/Right front of Mouse, Left/Right rear of house, Left/right side of house, Left J
Right side of building, Left i Right front of building, Left/Right rear df building, Under deck
Address
l .xj
Cityfrownn state Zip Code
2. System Owner:
Name
Address(if different from location)
Cityfrown stat ode
"telephone Number
i
,B. Pumping Record
2) C C
1. Pate of Pumping Cate 2. Quan"ty Pumped: Gallons
E
3. Type-of systerri: El Cesspools) eptic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yes o .,If yes,was it cleaned? ® Yes El No.
' S. Cond'tlo of stern•
. ; C9 t
4
6; System Pumped By:
Nell.Bateson ` F6821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contenterwere disposed:
rL Lowell Waste Water
Sign a Haul e Cate
t5fbrrm4.doce 06/03 system Pumping Record Page 1 of 1