HomeMy WebLinkAbout- Septic Pumping Slip - 131 GRANVILLE LANE 9/21/2018 Commonwealth
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Form 4
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DEP has provided this form for use-by local Boards 61"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 Board of Health to determine the forrh they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
1. System Location: Left/Right frpot of Mouse, Lett/Right rear of hour -�� lght e u Left
Right side of building, Left i Right front of buildirig, Left/Right rear of building, Under eC
Address
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/i ownSkate
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'telephone Dumber
B. Pumping pc r
1. Cate of Pumping Date G�� 2. Quantify Pumped:
Gallons
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3. Type-of system, Cesspool(s) eptic Tank ❑ Tight Tank 1
Other(describe):
4. Effluent Tee Filter present? Yep o If yes, was it Cleaned? ® Yes ❑ No,
5. Condition of System.
6: System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo ti or ontente,were disposed:
G LLowell Waste Water
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Sign a Hhul Crate
0brrn4.doo-06/03 System Pumping Record a Page 1 of 1