HomeMy WebLinkAbout- Septic Pumping Slip - 80 LOST POND LANE 9/24/2018 Commonwealth f Massachusetts
C it n of
a
Form
4 ; :. ' 'sy ''°
DEP has provided this forrfi for use�by local Boards 'of Health. Other form may'be"u ��,but the
information,must be substantially the same as that provided here. aefore using.this`roan,Check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to '
the local Board of Health or other approving authority.
A. Fac!Oty. In orMation
1. System Location: Left/Right front of house, Left/ .i.-hj mW f�Left/right side of house, Left/
Right side of building, Left/Right ffnnt of building, Left/Right ream of building, Under deck
AddressAl
�
-
Cityfrown state Zip Code
2. ,system Owner
Name'
Address Of different from location)
City/Town state Zip Ca ;
Telephone Number r w'
t
Pumping car
1. bate of Pumping oat 2. Quantity,, Gallons
3. Type-cf system: ® Cesspool(s) 11- eptic Tank ® Tight Tank
15 tither(describe). {
1
4. Effluent Tee Filter present? [ Yes o if yes, was it cleaned? E Yes ❑ No
r
5. Condition of System:
l w
6: System Pumped By:
Neff Bateson F5821
Name Vehicle License Number
Sateson Ehterprises Ina
Company
7. Lo W, re contents•were disposed:
L S Lowell Waste Water
sign a Hui Date
ftnM.doe•06f03 system Pumping Record°Page 1 of 1