HomeMy WebLinkAbout- Septic Pumping Slip - 145 CRICKET LANE 4/3/2019 Al
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Commonwe'alth of Massachusefts
City/Town
Sy.4tem Pumping, r
Form 4
DEP has provided this fora for use-by local Boards 'of-Health. Other forms maybe but the
information,must be substantially the tame as that provided here. Before using.this form,check with your
locdi Board of Health to determine the forth they use. The System pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facllity Inf®rmi anon
1. System Location: Let 1 house
a Left/Right rear of house, Left/right side of house, Left I
Right side of building, eft/Right frdnt o building, Left/Right rear df building, Under deck
. Address � �"G �� . �: •„�`:�`.. c',":'"� ` �..,'+.r �r'
City/'rown State Zip Code
2. System Owner. '
• Marne'
Address(if different from location)
Cityltown State
'telephone Plumber 3
i
Pumping C
1. Date of Pumping �eptfilcTank
-Pumped:Date p Gallons
3. Type-of systeft ® Cesspool(s) El Tight Tank 1
Other(describe):
4. Effluent Tee Filter present? 0 Yes o if yes, was it cleaned? [j Yes ❑ No
5. Condition af>Systen):
6: System Pumped By:
Nell.Batesbn ` F5821
Name Vehicle license Number
Bateson Ehterprises Ina
Company
l
7. Location where contents-were disposed:
Lowell Waste Water
9 Sign a hlhui Cate
t5forrn4.doe-06/03 System Pumping Record a Page 1 of 1
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