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HomeMy WebLinkAbout- Septic Pumping Slip - 16 WOODBERRY LANE 9/21/2018 Commonwe'alth ®f Massachusetts w City/Town of SyMem i . r "& I��°d Form 4 DEP has provided this formi for use=by local Boards of Health. tither forms bd 666d,lut the information,must be substantially the tame as that provided here. Before using.this form,check with your local Board of Health to determine the forrin they use. The System Pumping record must be submitted to the local Board of Health or other approving authority. A. Facflity. Informiation 1. System Location: Left/Right front of douse, Left/Right rear of house, Le trlMerde of hou Left Right side of building, Left I Right front of building, Left 1 Right rear of building, deck Andress Citylrown State Zip Code 2. System Owner. J Dame. Address(if different frarn location) City/Town ' State• Zi de f Telephone Dumber 1. ©ate of PumpingoatQ - 2. Quantity Pumped: Gallons r 3. Type-of systerri: (l Cesspool(s) Septic Tank Tight Tank Cher(describe): 4. Effluent Tee Filter present? Yes El No If yes, was It cleaned? E Yes ® No, • 5. Condition of System: Qr 6: System Pumped By: Neil.Batesbn ' F6821 Name Vehicle tmicense Number Bateson Enterprises Inc' Company 7. Location here contents,were disposed: ISIgn Lowell Waste Water a Haulev ®ate / t6forrn4.doc®06/03 System Pumping Record m Page 9 of 1