HomeMy WebLinkAboutSeptic Pumping Slip - 49 ORCHARD HILL ROAD 7/19/2018 Commonwealthf Massachusetts RECENED
City/Town of .
'JUL, 119 2018
Sy.4tem Pumping.Record ToWt4 OF NORM AW)OVER
Form 4
DEP ha'provided this for.M for 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 forma,check with your
local Board of Health to determine the form they use. The pystern Pumping Record must be submitted to
the local Board of Wealth or other approving authority.
A. Facility Information
1. System Location: Left/Right t of se Le /Right rear of house, Left/right side of house, Left
Right side of building, Left/Right fron of midi ' , Left/Right rear of building, Under depk
AddressrL ,� ,.�
city/Town State Zip Code
2. System Owner:
Address(if different from location)
Citylrown Stat +Zip Cop-7y)
Telephone Dumber
Pumping
9. Date of Pumping �2 Quantity Pumped:
p 9 Date m p Gallons
3. Type•of systaft El Cesspool(s) eptic Tank D Tight Tank
[� Other(describe): ,�-�
4. Effluent Tee Filter present? ® Yep Gj do If yes, was it cleaned? 0 Yes ® No,
' S. Condition of.system:
6: System Pumped By:
Neil.Sat - n F5821
Name Vehicle Ulcense Number
Bateson Enterprises Inc-
Company
7. Locati ere contents-were disposed:
L S. Lowell Waste Water
Sign a H We Date
t5fbnn4.doc-06/03 System Pumping Record•Page 1 of 1