HomeMy WebLinkAbout- Septic Pumping Slip - 104 SHERWOOD DRIVE 1/7/2019 Commonwealth of Massachusetts
City/Town of
Fonn 4
System Pumping Record
DEP has-provided this form for use-by local Boards of Health. Other forms maybebsed, 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 form they use. The system Pumping Record must be submitted t®
the local Board of Health or other approving authority.
A. Facility Inn orMation
1. System Location: L e ft K Q i-hnL—ttt front h�og Left/Right rear of house, Left/right side of house, Left I
Right side of building, Left 1 Right front of building, Left/Right rear of building, Under deck
. ..........
Address
CtwTown state Zip Code
2. System Owner.
Name'
Address Of different from location)
CiVrown Stater Zip Code
(-(f-?,3
Telephone Number
.B. Pumping lRecord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: 0 Cesspool(s) B-teptic Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? 0 Yes a--N�o If yes,was it cleaned? [I Yes El No
5. Condition of System,
6. System Pumped By:
Nell.Bates'on F6821
Name Vehicle Ulcense Number
Bateson Enterprises Ina
Company
7. Lopati"here contents-were disposed:
Lowell Waste Water
Sign a Haute Date
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