HomeMy WebLinkAboutSeptic Pumping Slip - 35 HOLLOW TREE LANE 7/23/2018 Cornmonwelgilth of Massachuseffs RECEIVED
Sy.4tem Pumping.Record
TOWN Or N m 1e�00 VE[,
or l u u r)i �td I N'
DEP has provided this forrri for use-by local Boards of Health. Other forms maybe`used,but the
information-must be substantially the same as than provided here. Before using.this form,check with your
local Board of Health to determine the foah they use. The;System pumping Record must be submitted to
the local Board of Wealth or other approving authority.
1. System Location: Lai t ofiu. , Left/Rlght rear of house, Left/right side of house, Left
Right side of building, Left 1 Right front of building, Left/Right rear of building, Under deck
Address
oltyrrown state Zip code
• f
2. System owner: _-
'
Address(if different from location)
city/Town • •. • Stated C �4 J--pp-Code ,
• p a•t
Telephone Number
Pumpingr
1. Date of Pumping2. Quantity Pumped:
Date Daltons
3. Type-of system/: Cesspool($) Septic Tank D Tight Tank
Ej Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes,was it cleaned? E Yes ® No
6. Condition of.System: � o ) +&tt
cc
6: System Pumped By:
Nell.Bates7on F6821
Name Vehicle license Number
Bateson Enterprises Inc'
Company
7. Locati a contents-were disposed:
P�S Lowell Waste Water
eigrigqe cfmwuleruDate
t form4.doc•08/03 System Pumping Record-Page 4 of 1