HomeMy WebLinkAboutSeptic Pumping Slip - 65 SUGARCANE LANE 8/26/2015 . l
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Commonwealths of Massachusetts r r �
City/Town of -���� � :
System Pumping-Record
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Form 4
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
1. System Location: Left t of house, Left/Right rear of house, Left/right side of house, 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.
Name'
Address(if different from location)
Citylrown ' State Zip Code
Telephone Number
B. Pumping JRpcord
1. Date of Pumping Date 2. Quantity Pumped: Gallons F
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of Sy t
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca` g bete contents were disposed:
G L S': Lowell Waste Water
-MOMf
SignAtube 9t Haule Date
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