HomeMy WebLinkAbout- Septic Pumping Slip - 488 SHARPNERS POND ROAD 1/7/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe"used, but the
Information,must be substantially the same 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. Facility Inform' ation
1. System Location: Left/Right front of house, Left/Right rear of house, U@7 right lgdj�o Left 1
Right side of building, Left/Right front of building, Left/Right rear(if building, Under deck
Address T,::T
cityfrown state zip cotle'
2. System Owner.
Name'
Address(if different from location)
City/Town State,q (? :�>>:v— Z Code
Z,
Telephone Number
.B. Pumping ftecord
9. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system., E] Cesspool(s) 3--§�Sprlc Tank E) Tight Tank
El Other(describe):
4. Effluent Tee Filter present? Ej Yes al,40 If yes, was it cleaned? E3 Yes El No
5. Condition of System:�jvr�c
6. System Pumped By:
Nell.Batesabn F5821
Name Vehicle Uteense Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
Lowell Waste Water
Ze Date
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