HomeMy WebLinkAbout- Septic Pumping Slip - 201 HAY MEADOW ROAD 1/7/2019 Commonwealth of Massachusetts
City/Town of
n.
System Pumping Record
Form 4
DEP has provided this form for use.by local Boards of Health. Other forms maybe 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 to
the local Board of Health or other approving authority,
A. Facifity InforMation
1. System Location: Leh/Right front of house, Left I Right rear of house, Left/right side of house, Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
1:)-0 k i� CIL-) -9-r
cjtyfrown state Zip Code
2. System Owner: (j
Name'
Address(if different from location)
City/Town stater
I (D[ I e3p Code
Telephone Number
.B. Pumping Kecord
1, Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: E] cesspool($) 3-s6pric Tank 0 Tight Tank
[3 Other(describe):
4. Effluent Tee Filter present.? Ej Yes 0-140-� If yes, was it cleaned? [j Yes E] No
6. Condition of System: tjacvth-CA
L,
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location-where contenterwere disposed:
Lowell Waste Water
Sign a # ule Date
t5fbnn4.dof.-08/03 System Pumping Record•Page 1 of 1