HomeMy WebLinkAbout- Septic Pumping Slip - 109 SAW MILL ROAD 1/8/2019 Commonwealth of Massachusetts
City/Town of
System Pumplang Record
M
Form 4
DER 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.Tate System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Inform' ation
9. System Locatlo : ' ZRI&KQE�f�hou Left I Right rear of.house, Left/right side of house, Left I
Right side of biI1Fngg'jLeft I Right front of building, Left/Right rear of building, Under deck
Address
t0q _ '0
City/rown state Zip Code
2. System Owner:
-----------
Name'
Address(if different from location)
City/I awn State Z*C d a
Telephone Number
13. Pumping K-ecord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: E] Cesspool($) &Ie—p-tic Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? E] Yes o If yes, was it cleaned? El Yes El No
6. Condition of System
6. System Pumped By.
Neil,Bates7on F5821
Name Vehicle License Number
Ba!eson Enterprises Inc,
Company
7. Locafii:%nwr contents-were disposed:ter'We Lowe"Waste
G.LS'J? Lowell Waste Water
C.
e Date
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