HomeMy WebLinkAbout- Septic Pumping Slip - 138 OLD CART WAY 1/8/2019 Commonwealth of Massachusetts
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City/Town of
System Pumping r
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Form 4
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DEP has provided this form for use-by local Boards of-Health. Other forms may `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 forrh they use.The;system Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Inform' aflon
1. System Location: Left/Right front of house, Left t rear of h Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address � � /� `�Cam-' ��� W I`•.�C.�� .
City/Town '✓ state Zip Code
2: System Owner.
Name.
Address Of different from location)
City/Town ,tat ( 7 Zip`"L &IDID
Telephone Number
® Pumping Record
1. Date of Pumping �� �C �UuixPumped: � J
DateGallons
3. Type-of system: E] Cesspool(s) k [] Tight Tank
® Other(describe):
4.. Effluent Tee Filter present? El Yes o If yes, was it cleaned? [ Yes ® No
5. Condition of System:
6. System Pumped By:
Neil Beteson F5821
Name Vehicle License Number
_S_ateson Ehtervrlses Ina
Company
7. Location where contents-were disposed:
L S Lowell Waste Water
Sign a Hhul Date
t5farm4.doo-06/03 System Pumping Record a page 1 of 1