HomeMy WebLinkAboutSeptic Pumping Slip - 143 DUNCAN DRIVE 7/2/2018 Commonwealth
RECEIVED
• i
W ► own of .
Sy.4tem Pumping,Record
(Form 4 TOWi4 OF OMK AIOM�
HEALTH OEN,Ftl MOT
DEP has-provided this form for use-by local Boards of Health. Other forms maybe*used,but the
information'must be substantially the same as that provided here. Before using.this form,check with your
tocol 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. Facflyty InforMation
1. System Location: Left I Right franc pf Ficus a Rig ar�rear
, Left l right side of house, Left I
Right side of building, Left/Rig6t front of b inga, Left/Rigbuilding, Underdeck
Address
Cityf town State __ yip Code
2. System Owner.
• raamg
Address(if different from location)
CityfTown state• 4 C� 'ire de
'telephone Number
r
Ppaiping K 'eco ' `
e-.",.
1. ®ate of PumpingQuant,aty Pumped: �
•
tate Gallons
3. Type-of system: El Cesspool(s) Septic Tank D Tight Tank ,•
® tither(describe):
4. Effluent Tee Filter present? s 'No If yes, was it cleaned? es ® No.
5. Condition of.System:
6; System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
.l S Lowell Waste Water
Sign a Hbuie Date
151orrI 08/03 System Pumping Record m Page 1 of 1