HomeMy WebLinkAbout- Septic Pumping Slip - 141 MARIAN DRIVE 8/28/2018 Commonwealth u
City/Town of
SY.4tem Pumping,Record AUG .2 8 2018
Form 4
l 431-1 D cPI�Rl ;la:.�
DEP has provided this form'for use-by local Boards o'f,Health. Other forms may be used,but the
Information-must be substantially the tame as that provided here. Before using.this fora,check with your
l
local Board of Health to determine the forrh they use. Tile System Pumping record must be submitted to
the local Board of Health or other approving authority. 1
' J
A. Facflity. information"
1. System Location: Left/Right front of house, Leftt rem or f ho�us. , Left/right side of house, Left l
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/1 own State Zip Code
2: System Owner:
' Name'
Address(if different from location)
Citylrown ' State .. - Ce
P Telephone Number u
t
.13. Pumping Rpeord
i
1• Crate of Pumping ®ate 2. Quantity Pumped: Cellons �--- -"
3. Type-of system � G spocl(s) Sept►c tank Tight Tank `
® Other(describe):
4. Effluent Tee Filter present? 0 Yep No If yes, was it cleaned? ® Yes El No,
' 5. Condition of System:
c
6. System Pumped By:
Nell.Batesibn F5621
Name Vehicle License Number
Bateson Ehterprises Inc
Company
7. Location where contents-were disposed:
Lowell Waste Water
ioCate
t fotmA.docd 06/03 System pumping Record g page 1 of 1