HomeMy WebLinkAboutSeptic Pumping Slip - 149 MARIAN DRIVE 8/28/2015 Common wealth of Massachusetts
City/Town of
System Pumping.Record
Form 4
DEP has provided this formlor use-by local Boards of Health. Other forms may be 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
I. System Location: Left/Right front of house, e lghK ear of house Left/right side of house, Left
Right side of building, Left Right front of bSi P?inhgg., Left Rgigi�reardf building, Under deck
Address
. t 1-1(
citty/rown State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town - Coe
Telephone Number
B. Pumping Rpcord
1. Date of Pumping Date entity Pumped:
Gallons
3. Type-of system: El Cesspool(s) Septic Tank F-1 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 3--No If Yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of.System:
Ll �A
6.- System Pumped By.,
Nell.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Loc!a',=Whe contents-were disposed:
LS Lowell Waste Water
S19nAtu.fe 9t HauleV— Date
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