HomeMy WebLinkAbout- Septic Pumping Slip - 29 BARCO LANE 11/26/2018 Commonwealth of Massachusefts
City/Town of
RecordSystem Pump"Ing
�
Form 4
C� �, 0� ph
DEP has provided this form for use:by local Boards of Health. Other forms�ey be'used, but the
information•must be substantially the same as that provided here. Before using.this farm,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local ward of Health or other approving authority.
A. Facift Information
1, System Location; L /Right front of house, Lett/Right rear of boos. e ugh ides hous , left
Right side of building, Left/Right front of building, Left/Right rear of bur rng, Under d&ck~mm.-m
Address
cityfrown State Zip Code
2. System Owner:
c,
Name'
Address Of different from location)
cityfrown Slat iCode
Telephone Number
Pumping Ir p
1. ®ate of Pumping Date 2. Quantity Pumped:
Canons
3. Type-of system: Cesspool(s) eptic Tank [I Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes, was it cleaned? ® Yes El No
5. Condition of st m
:
------------
6. System Pumped By:
Pfeil.Satesbn F5821
Name Vehicle License Number
Sateson Enterprises Ina
Company
7. Locattn,wbere.contents.were disposed:
Isign
Lowell Waste Water
a pHoulo Date
t6form4.doc-06/03 System pumping Record d page 1 of 1