HomeMy WebLinkAbout- Septic Pumping Slip - 48 PADDOCK LANE 9/21/2018 fts
Commonwealth !f
018
nSy.4tem Pumping, r .
Form 4
DEP has provided this form far use.by local Boards of Health. Other forms maybe`used,but the
information-must be substantially the tame as that provided hare. Before using.this form,check with your
local Board of Health to determine the farm they use. The System Pumping Record must be submitted tc
the local Board of Health or other approving authority.
X.--FaCIRty, r Mation
i
I. system Location: Left/Flight front of house, Left �lghr ,Left/rightslde of house, left/
Right side of building, Left/Pight front of building, building, Under deck
Address
�(� y ✓'
Citylrown State Zip Code
2. System Owner. r
Name'
Address(if different from location)
Citylrown State Zip Code
p Telephone Number `',
t
Pumping sc
1. Date of PumpingCate 2. Ouanti Pumped: Gallons -----`
3. Type-of system: El Cesspool(s) eptic Tank Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes a If yes, was it cleaned? 0 Yes ® No,
" 5. Condition of System:
6: System Pumped By:
Neil.Bateson F6821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. o do re contents-were disposed:
G L0�� Lowell Waste Water
y
Sign Date
1:51orm4.doc•06/03 System Pumping Record d 'age 1 of 1