HomeMy WebLinkAbout- Septic Pumping Slip - 142 DUNCAN DRIVE 4/3/2019 Commonwealth of Massachusefts
City/Town of
RecordSy.4tem Pumping. �,� A
`- Form 4
DEP has provided this forfri for use-by local Boards of Health. Other fore may be'used,but the 1
information'must be substantially the tame as that providedhere. Before using.this fora,check with your 1
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. Facloty. inf®r ti n
1. System Location: Lift/Right front of douse, Left/Right rear of h®us , e_ lig side of hou ;�Left
Right side of building, Left/Right front of building, Left/Right rear of bu'Iding, Un
Address
CitylTawn state Zip Code
2'. System Owner:
Name-
Address Of different from location)
City/Town � '. State,n r Zip Code ,
a "telephone Number i+`mow
r
r
4 Pumping Rgeord
- `
1. Cute of Pumping Crate 2. Quantity Pumped:
Gallons
3. Type-of systerri: El Cesspool(s) eptic Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present? ® Yet E3,1qo If yes, was it cleaned? Yes ❑ No
` 5. Condition of System:
6: System Pumped By:
Neil.Sateson F5621
Name Vehicle License Number
i
_Bateson Enterprises Ina
Company
7. Lo where contents-were disposed:
G L S. Lowell Waste Water
egn a Mule Cate
t5farmd.doc-08/03 System Pumping Record•page 1 of 1