HomeMy WebLinkAbout- Septic Pumping Slip - 86 SHERWOOD DRIVE 5/1/2019 ,if
L we T
Common 61th o'p Massachusefts
Uty/Town of
1A 1,11,
S- em Pumping, Record .........
S Y
Form 4
DEP has p rovided thi's form for us&by local'Boards of,Health. Offer formit may. I 'used, but the
information-must be subst6nflally the tame as that provided here. Before,Wth rig. is form,check w th your
110061 Board of Health 6 date,rmine the fog they MO they use. The$ i , co st s itte to
the local Board of Healt�h or other approving authority. ystem Pump ng Re rd mu be ubm d
Facility Infor Mation
1. System Locaflo ig of ho Left/Right rear of house, Left/right side of house,, Left I
!?a.>i 'qNiaiif�ro6nt of b�i
Right side Of buit, g, Left I Right ujidifig, Left/'Riglht,rear cif buildm" g, Under deck
Address I.,..........
01ty/Town state Zip Code
2. System Owner.
Name'
Address!(if different from location)
Citymwn State-,,,� Zip Code
Telephone Number
.B,. Pumpll,ng Record
%Wool'
anu ..................
1. Date of Pumping Date wu,anti umpe
I Type-of system:,, El cessp fi k
ool(s) a c Tank Tight Tan
�p
Other(describe) .... ........
4. Effluient Tee Filter present? El 'Yes 011t ro� If yle"s,,, was it cleaned? [3- Yes El No
0
5. Condition of System,
6, System Pumped By,-,
Nell.Batetbn 17,58,21
Nam e Vehicle License Number
Beteson EqLemr1ses; Inc-
Company
7. Lo ere content&were disposed,
ML Lowell Waste Water
'At
10*
Sign 0 13 Date
CfH
t5fbrm4.d,oc*06/03 System Pumping Record Page 1, of 1