HomeMy WebLinkAbout- Septic Pumping Slip - 52 NORTH CROSS ROAD 1/8/2019 (3) Commonwealth of Massachusefts
City/Town of
System Pumpling Record
Form 4
DEP has provided this form for use by local Boards of Health.Other forms maybeused, 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 Inn orm' sition
1. System Location: Lek/Right front of house, Left/Right rear of house, Left/right side of house, Left I
Right side of building, Left Riglit front of building, Left I Right rear of building, Under deck
Address
cityfrown state Zip Code
2. System Owner
Name
Address Of different from-
cityfrown stat%7� Z' Cad C
Telephone Number
® Pumping Record
1. Date of Pumping Date 2. QUMIbPumped: Gallons
3. Type-of system: El Gesspool(s) epr ic Tank 0 Tight Tank
[] Other(describe):
4. Effluent Tee Filter present? El Yes 01M� If yes, was it cleaned? El Yes El No
5, Condition of System:
S. System Pumped By:
Nell.Meson F6821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Logation- re conte nter were disposed:
Lowell Waste Water
Sign e Hbul Date
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