HomeMy WebLinkAbout- Septic Pumping Slip - 167 DUNCAN DRIVE 9/21/2018 Commonwealth of Massachusetts
City/Town of
Syitem Pumping,Record
Form 4
DEP has provided this form'far use.by local Boards 6f Health. Other forms maybe'used,but the
information,must be substantially the same as that provided here. Before using.this form,check with your
local ward of Health to determine the farm they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facfl�ty Informiatiom,
I. System Location: L Ig t front of Crouse of!Right'rear of house, Left./right side of house, Left
Right side of building, Le Ig ron o uild!fg, Left/Right rear of building, Under deck
Address p
Cityrrown state Zip Code
2. System towner: 1
Name'
Address(if different from location)
Cityfr'own State • t , F Ip Code
Telephone Number
i
® Pumping r
1. Date of Pumping 2. Quen`ty Pumped:
Date Gallons k
3. Type-of system: Cesspool(s) eptic Tank Tight Tank
El Other(describe):
. I
• 1
4. Effluent Tee 'Filter present? ® Ye o if yes,was it cleaned? ❑ Yes No
5. Condition of System:
6: System Pumped Ey:
Nei!Eates7on ' 'F5821
Nage Vehicle License number
_Bateson Enterprises Inc,
Company
7. Loca ' contents were disposed:
G L . Lowell Waste Water
. E
,Sign e Hb to Date
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