HomeMy WebLinkAbout- Septic Pumping Slip - 29 NORTH CROSS ROAD 11/26/2018 Commonwealth of Massachusetts 3 D
W1,ECEP41'E
City/Town of
system Pumping Record
Form 4 ,pf
C,
DEP has provided this form for use-by local Boards of Wealth. Other forms may bebsed,but the
information,must be substantially the tame as that provided here. Before using.this form,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.
A. Facility InforMation
1. System Location: Left/Right front of house, Left TRIght rear q ho.u* Left./right side of house, Left
._.fqa
Right side of building, Left I Right front of building, Left/Right rear of building, Under deck
Address (2
City/Town State Zip Code
2. System Owner
Name'
Address(if different from location)
cityrrown Stater
Telephone Number
® Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: El Cesspool(s) U_Se�prlc Tank [I Tight Tank
El Other(describe):
4. Effluent Tee Filter present.? El Yes El-fqo- If yes, was it cleaned? Yes Q No
5. Condition of System: I I
6. System Pumped By:
Neff.Bates7on- F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lo tion- fir-O content were disposed:
Lo Uo wrie ",weed,5po
G, S. Lowell Waste Water
_.k
wrl Date
Sign a
tMrm4.doc-06103 System Pumping Record Page 1 of 1