HomeMy WebLinkAboutSeptic Pumping Slip - 54 OLD CART WAY 8/27/2015 Commonwealth of Massachusetts vIA,"D
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City/Town of I ,AH
System Pumping-Record
H
Form 4
DEP has provided this formlor usezby local Boards of Health. Other forms may be'used, b'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
I. System Location: Left/Right front of house, Left I Right rear of house, AM2e!!o!fh:o:u ,Left
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. 0 t�� .
Name'
Address(if different from location)
cityrrown state Zip,Cod e
Telephone Number
B. Pumping Ripcord
1. Date of Pumping Date 2. Quantity Pumped: Lallans
3. Type-of system*. ❑ Cesspool(s) 0-6-6-plf-lc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep E3`ho If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
6.- System Pumped By:
Nell.Batesbn - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contentsr were disposed:
G- .S.Q, Lowell Waste Water
=-L S.
Vile Pa
Sign Haule Date
t5form4.doo-08/03 System Pumping Record•Page I of I