HomeMy WebLinkAboutMiscellaneous - 66 HAY MEADOW ROAD 8/14/2015 Commonwealth of Massachusetts RECEIVED
City/Town of
2 4
System'tem Pumping.Record
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Form 4 °TO\Ntj OF eq JO. R c c—i AK*VER
DEP has provided this form for use=by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility, Information
L e high o i6Wf�1��6s Left, right side of house, Left
1. System Location: Left/Right front of hous ,: 1
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
cityfrown State, Z' Code
Telephone Number
B. Pumping Record
1. Date of Pumping ---ntity Pumped:
Date Gallons
3. Type-of system. ❑ Cesspool(s) S-Se-p-fic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? E3 e§ ❑ No If yes, was it cleaned? [3-Ye—si"'ff"No
5. Condition of System:
6.- System Pumped By:
Nell.Batesion F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location Wie`e,,contents were disposed:
S. Lowell Waste Water
'C-) U
Sign Atu I A 9t HauleV Date
t5form4.doo-06/03 System Pumping Record•Page 1 of 1