HomeMy WebLinkAbout- Septic Pumping Slip - 251 GRANVILLE LANE 11/26/2018 Commonwealth of Massachusetts
RECEIVED
City/Town of
System Pumpling Record
Form 4 ,fo�NN OF NOPIH Atg�)VER
HEA 01-1,[)I V>ARTMEN,r
DEP has provided this form for use-by local Boards of Health. Other forms maybe used, but the
information-roust be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use. Tire System Pumping Record must be submitted to
the local Board of Health or other approving authorlty.
A. Factilty Inform' ation
1. System Location: Loft/Right front of housere g Ir'0 Right 00�=�f hcu7 )Left-/right side of house, Left I
Right side of building, Left Right front of bu ldIfig, Left/Right reaFdf'6uiIdIng, Under deck
Address
City Town State Zip Code
2. System Owner
Fw
Name'
Address(if different from location)
Cityrrown Stater Z' Code
Telephone Number
® Pumping Record
1. Date of Pumping 2. Qu&nqty Pumped:
Cate Gallons
3. Type-of system: Cesspool(s) ale—p—ric Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? E) Yes 01N�o If yes, was it cleaned? D Yes El No
5. Condition of Syst
6. System Pumped By:
Nell.Batetbn F5821
Marne Vehicle License Number
Bateson Enterprises Inc 1.
-
Company
7. Locatiorrwherye contents-were disposed:
1G, Lowell Waste Water
Sign e Haul Date
tftrm4.doo-08/03 System Pumping Record Page 1 of 1