HomeMy WebLinkAbout- Septic Pumping Slip - 70 LOST POND LANE 11/26/2018 Commonwealth of Massachusetts
City[Town of
System Pumping Record
Fonn4
DEP has provided this form for us&by local Boards of Health. Other forms maybe'used, but the
information-must be substintially the tame as that provided here. Before using.this form.,Check with yotir
local Board of Health to determine the forrh they use. The System Pumping Record must be submitted tc)
the local Board of Health or other approving authority.
A. Factlity Infor Mation
1. System Location: Left/Right front of house, Left/t1j"C re�r.Rf oyj� Left!right side of pause, Left I
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Right side of building, Left Right front of building, Ce-ft-Widfit"rear-(if building, Under deck
Address
A,
Claytrown State Zip Code
2. System Owner:
Name
Address(if different from location)
CityfTown State ZiPtr de
Telephone Number
-13. Pumping K-ecord
-.4
1. Date of Pumping Date e_ WMID11tyPumped: Gallons
3. Type-of system: El Cesspool(s) 01septic Tank Tight Tank
E3 Other(describe): 11 ,,-
4. Effluent Tee Filter present? 0 Yes 040 If yes, was it cleaned? Yes ❑ No
6. Condition of System-
6. System Pumped By:
Nell,Eat es7on F5821
Name Vehicle License Number
BgLe�an Enter�,rises Inc....
Company
7. Locati re contents-were disposed:
10-LLS: Lowell Waste Water
Sign ign a H'ailul ulev Date
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