HomeMy WebLinkAboutMiscellaneous - 546 SHARPNERS POND ROAD 8/14/2015 Commonwealth of Massachusetts
City/Town of RECEIVED
S
Y item Pumping.Record 03 2 4 ?n,"i
S
Form 4
T(I'MN OF 1,40KH 04DOVER
DEP has provided this form'for use4 by local Boards 6.f Health. 06648M" - 'used, b'but the
information-must be substantially the tame 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
1. System Location: Left/Right front of house, Left Right rear of house, Left
tlgh�17slide�-of
khq§o, Left/
Right side of building, Left Right front of building, Left/Right rear of building, �erec
Address
city/-rown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town Stater i de
C
Telephone Number
B. Pumping Record
q_
1. Date of Pumping Date 2. Qu6ntity-Pumped:
- Gallons
❑ Cesspool(s)
3. Type of system; 04eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep 3--'No If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of.System:
6; System Pumped By.,
Nell-Bates7on - F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Locatio"her contents were disposed:
GJA l Lowell Waste Water
Sjgne WHaule Date
t5form4.doo-06/03 System Pumping Record•Page 1 of 1