HomeMy WebLinkAbout- Septic Pumping Slip - 125 SAW MILL ROAD 1/8/2019 Commonwealth of Massachusefts �
i n if ggg
i 0System i
Form 4
DEP has provided this form for use�by local Boards of Health. Other forms maybe*used, but the
information-roust 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 bumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Inform' siflon
1. System Location: Left/Flight front t�f house, Left/ .�t rear of hour, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Fight rear of building, Under deck
Address + ,
city/Town State dip Code
2: system Owner V
Name'
Address(ir different from location)
city/Town stat '� o� Code
Telephone Number
Pumpingcor
1. bate of bumping pate 2. Quantity bumped:
Gallons
3. Type-of system: Cesspool(s) eptic Tank E) Tight Tank
Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes,was it cleaned? 0 Yes ❑ No
5. Condition of System:
6. System pumped By:
Nell.Eateson F5621
Name Vehicle License Number
Satason Enterprises Inc-
Company
7. Lo re contents-were disposed:
t
CrL Lowell Waste Water
i
Sign a Hhui Date
tMM14.doo•06/03 System Pumping Record*Page 1 of 1