HomeMy WebLinkAbout- Septic Pumping Slip - 101 SHERWOOD DRIVE 10/2/2018 Commonwealth of Massachusetts
City/Town of
Sy
j OVER
Form 4
DEP has provided this form for use-by local Boards 6f Health. Other forms maybe`used,but the
information-must be substantially the tame as that provided here. Before using.this fora,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.
• f
. F cfll y Informi atlon
Dose a ight rear of house, Left/right side of house, Left I I. System Location; Lei/Fight of `
Bight side of building, Lest I Right fr6-nT of building, Left I Right rear of building, Under deck
Address ,
Citylrown State Zip Code
2: System Owner;
AJame'
Address(if different from location)
Cityrown stater Zip Code
Telephone Number
B. u . Fin pc
ord
1. ®ate of Pumping crate �eprlucaTa,,nk
, ity Pumped; Gallons
3. Type-of system: El Cesspool(s) E) Tight Tank
Other(describe): j
- i
4. Effluent Tee Filter present? ® Yes M11fo If yes, was it cleaned? ® Yes C] No.
5. Condition of System;
—M16J
6; System Pumped By;
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc"
Company
7, Loqjatioq a contents were disposed;
L S Lowell Waste Water
Sign a Houle Date
t5lbrmCdoc-06/03 system Pumping Record a Page 1 of 1