HomeMy WebLinkAbout- Septic Pumping Slip - 136 SAW MILL ROAD 10/31/2018 �,,,.Gr li�C.:ir4 tl��/✓/h lei%�
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System Pumping Record �,EALTH DEf-A[�TWEENT
` Form 4
DEP has provided this form for use.by local Boards of Health. Other forms may be'used,but the
Information-must be substantially the same as that provided here. Before using.this form,check with yotir
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. Facility Inform' aflon
1. System Location: Left/Right front of Mouse, Left/Right rear of hous righ 1 e hwse,a eft J
Right side of building, Left I Right front of building, Left I Right rear bl ing, Un er ec
Address v`C-
City/rown Stag Zip code
2. System Owner: A
Name'
Address(if different from location)
Civrown state Z' Code
'telephone Number
Pumpling Record
1. rate of Pumping Date 2. Quantity Pumped:
�. Gallons
3. Type-of system: El Cesspool(s) eptic Tank El Tight Tank
Other(describe):
4. affluent Tee Filter present? es El No If yes, was it cleaned? T-ff No
5. Condition of System:
l
. System Pumped By:
Nell.Bates-on F5321
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo .o were contente,were disposed:
G L Lowell Waste Water
Sign RHaul
Date
t5form4.doo-06/03 System Pumping Record®Page 1 of 1
