HomeMy WebLinkAbout- Septic Pumping Slip - 32 EQUESTRIAN DRIVE 1/8/2019 Commonwealth of Massachusefts ")
City/Town of
System PAPB mpling Record
Fonn 4
DEP has provided this form for use-by local Boards of Health. Other forms may be�usie`,'64t'the
information-must be substantially the same as that provided here. Before using.this form,check with yotir
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 I Right front of house a A ig iear ofhou Left/right side of house, Left I
iha L,
Right side of building, Left Right front c ii ifig, "eft ear of building, Under deck
Address
City/Town state Zip Code
2. System Owner
Noma'
Address(if different from location)
City town state- J? 41].Code
Telephone Number
,13. Pumping K-ecord
1. Date of Pumping — 2. Quantity Pumped:
Date Gallons
3. Type-of system: E] Cesspool(s) 9 -e-p r-1-0,Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? 0 Yes 0,-ab� If yes, was it cleaned? E) Yes [I No
6. Condition of System:
6. System Pumped By:
Nell.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents-were disposed:
ztL S�R 5�1) Lowell Waste Water
Lsign9AWFo PH6u1edEd2!-- ®ate
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