HomeMy WebLinkAbout- Septic Pumping Slip - 74 STONECLEAVE ROAD 7/2/2019 i
e
e
wI
RE C
e CRY/Town of
Commonwealth of Massachusefts 'ED
YS R
tem Pumping'.Record
NOF
Form 4
DEP has
rovided this fbim'for
by local Boards 6fHealffi. Other formis may'bel'Used', ut the
d
J,
�� r � *must be substantially the tame as that provided here. Before usingAhis foffn,check with your
Boardin i 1
localthe Board of Healthapproving
e
A. Facfl�ty Infor Matillon
r
N
T
SystemLocation: Le "Right front of house, Lei �us�%-Ieft- right side of house, Left I
side l"Idin , Lei Right fr6nt of buildifig, Left, Right rear cif buildirig, Under deck
e
Address
crown State Zlip Code
1, System wner,
Name
e � ,
1
Addressdifferent from to fl
C '
Wa �;�
t
e � � t
k e
Telephone Number
�tl
.B.
e ..
Pumping
w
ecord
117
w
. Date of PumpingDate 2. Qu6nti Pumped. Gallons
c
. Type-of sy�eft Cesspool(s) c Tank Tight an 1
Other(describe):
Filter r If yes, was it,cleaned?
. Condition of System:,
w w e
y.-,
a
w
Name Vehicle n Number
1 w
Company
7. Location wherer i w
t
WaterLowell Waste
.e
Him
�w
� ! Date
t6fbtm4.doea,06,103 eSystem Pumping Record Page,1 Of 1