HomeMy WebLinkAbout- Septic Pumping Slip - 40 DUNCAN DRIVE 6/4/2019 M1
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Commonwealth
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City/Town of
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System Pumpi"no
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Form 4
DEP has
provided this fbrm for useoy local Health. Other r may, "used,,Out
the
i r a. -must s s d the tame as that provided here. Before using.his form,check wi ith.your
i l Board of Healthto,determine the for, they use.The$ystern,Pumping Records �e submitted,to
the,local, Board of Health or other approving authority. .
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AW Facility InforMation
1. System Location: Left it Right front of house, Left MRIJ�hti ear,of.hou' 'A' eft. right side of house
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Right ibuilding, Right,y bbuilding, -i y � �
Address
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fate 4 Code,
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Address different from location)
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COLWO
W " fa V Code
Telephone Number
.B. Pumplang Record
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ry
. Pumping . aPumped:
ores
& Type-of s st w: Cesspool(s) D4W k Tightank
Otheraia
4. Effluent Tea Filter present? 0, Yap � i yes, was ft cleaned [J Yes Eli No
6. Condition of System:
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System Pumped Byi
Fail. B7
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Narne Vehicle License Numbleir
Bateson
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NO I
Company
G, a. Lowell Waste Water
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-Houle! Date
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