HomeMy WebLinkAboutSeptic Pumping Slip - 152 MILL ROAD 6/6/2018 Commonwealth u
Cit�/Town of
System Pumping.Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other farms may be'used,but the
Information-must be substantially the same as that provided here. Before using.this fora,check with your
locail Board of Wealth to determine the form they use.The;System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. acflity. Inf r ti n
1. System Location: L it..� flhkonmsd, Left 1 Right rear of house, Left./right side of house, Left t
Right side of building, Left 1 Right front of building, Left I Right rear of building, Under deck
Address
Citylrown State zip Code
2. System Owner:
Mame`
Address(if different from location)
Citylrown ` Stat `
Code
f
"telephone Number
Pumpling Rpcord
1. Date of Pumping Bate 2. Quantity Pumped: Gallons �.
3. Type s stem:
yp system* ❑ Cesspools) 0--septic Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes Na If yes, was it cleaned? ® Yes ❑ No,
' S. Condition of Sy to
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Dumber
Bateson Enterprises Inc
Company
. Locati `krel contents,were disposed:
S Lowell Waste Water
Sign a Haul gate
t6form4.dooa 08103 System Pumping Record*Wage 1 of 1