HomeMy WebLinkAbout- Septic Pumping Slip - 41 CROSSBOW LANE 5/1/2019 Commonwealth of Massachusetts
CRY/Town I J
of
I ti Bpi
g )\4
System Pumpin Record
i k_)
Form 4
DEP has-provided this form for us&by local Boards of flealth. Other form�,may'be*Used,but the
information- st be subst6ritially the tame as that, provided here. Before using Ahlsform,,check with your
loc,61 Board of Health t6 determine the for M4 they use. TheSystem Pumping Record must be Submitted to
the local Board of Health or other approving authority.
Faci-lit InfbirMation
Y
1. RSyigshtet ms Location: Left, Right fgrolint tf rnt of bu go Left,
/ gideo ,
id i Ri6 Left I
o, building, Under deck
Address
Uj
efty/Town state Zip Code
2. System Owner.
Name'
Address Of different from location)
ciwown
L/
Telephone Number
.B. Pumping Record
1. Date of Pumping 2. Qu a*nfity Pumped: -------
Date Gallons
e
,3. Type-of systerni: El Cesspool(s) alt ptic Tank D Tight Tank
Other(describe):
4. Effluent Tee Filter presentl. Ye�s 10 If yes, was it cleaned? Yes IE] No
ER00 o
5. Condition of stem,:
t4000Q
6., System Pumped By.-,
Nell'.Batesb F6821
Name Vehicle,License Number
Bateson Ehte!pr*lses Ina
Company
7. Locau"o, conten isposed,
Lowell Waste Water
%woe
Sign I-Mb—lut Date
t51brm4.doo&06/03 System Pumping Record page 1 of I