HomeMy WebLinkAbout- Septic Pumping Slip - 56 CRICKET LANE 5/1/2019 Commonwealth of Massachuseffs
CRY/Town
AAl p
System Pump"Ing Record
Fonn 4
DEP has
provided this form for ,.by local Boards r formis may.fie"used,but the
inform n, ,t substantially the tames that Before i �s f �,�checkwith your
loc6l Board of Healthdetermine� h y use.TheSystem Pumping Record must be submitted to1
the local Board of Health or other approving authority.
A. Facility Inform' ation
" fig, Left gil � � ,.w r� side houses
System Location: Right front house,build� r w eLeft I
Right side of building, Left, Right, fr6nt of
rear df building, Under deck
C #T Zip
. System Owner:
mn
Name
II
Address from l
ckwownde
Telephone Number,
.
B. Pumping Pecord
�_ w
.. Date Pumping 2. u6tyPumped:
DateGallons
Otherank
3. Type-of system" El Cesspool(s) 0-ftp,�icTank, Tight T
(describe):
Effluent,4. f r nth" if yes, was it cleaned? Yes No
5. i `gin a
System6. By,:
Nell. 2
Name Vehicle License Number
company
MF Locau"on-where,contentsr I
* I
Lowell Waste
d,.,. . Water 1
m
r
S'Ign libul Date
t6formCdoeb 03 System Pumping Record Page