HomeMy WebLinkAboutSeptic Pumping Slip - 45 TURTLE LANE 6/6/2018 Commonwealth huCit�/Town of
Y j
• -•� j G Pumpling.Record
` Y l l ol"�"1 1�
Form 4
DEP has provided this form for use-by local Boards 61'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 form 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 deg.
fight �roolnito�OUSLU-ildifig,
Left/Right rear of house, Left/right side of house, Left/
Right side of buil �ft/Rlg Left/Right rear of building, Under deck
Address
Cityrrown state Zip Cade
2. System towner:
Name.
Address of different from location)
cityirown state- , / - Zi Code
P
Telephone Number
i
r
tt p 111
1. mate of Pumping cote 2. Quantity Pumped: Gallons
3. Type-of s stern: i
yp y. Cesspool(s) - eptic Tank ❑ Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yes o if yes, was it cleaned? E Yes ® No,
' 5. Condition of System: i I �f``.•n.���.`�C�,�� /�-•-��%�,_ �i ✓�.,
S. System Pumped By:
Pfeil.Bateson - F6821
Name Vehicle!_4cense Number
Bateson Enterprises Ina
Company
7. Location—where contents-were disposed:
ISign
Lowell Waste Water
Hihmla Date
0brm4.doca 06/03 system Pumping Record a Page 1 of 1