HomeMy WebLinkAbout- Septic Pumping Slip - 89 MARIAN DRIVE 3/4/2019 Commonwealth fi Massachusetts
aCityfTown of
o System u ping Record
Form 4
DEP has provided this form for use�by local Boards of Health. Other forme may be'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.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facift Inform' ation
1. System Location: Left/Pight front of hous4 WhMg r ousa, eft/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rein R-66iiding, Under deck
Address
'.Qck
City/Town State Zip Code
2. System Owner: '-
Name
Address Of different from location)
City/rown State ip Cp
Telephone Number
® Pumping Kecord
1. ®ate of Pumping Date ;:2. Qua City Pumped: Gallons
3. Type-of system: Gesspool(s) eptic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? es ® No If yes, was it cleaned? s ® No
5. Conditi n of Syst m:
6. Syste rn Pumped By: /
C �c _ . �.
Nell.Bates on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio ere contents-were disposed:
LL S: Lowell Waste Water
Sign a Haute Date
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