HomeMy WebLinkAboutSeptic Pumping Slip - 66 CEDAR LANE 8/21/2015 Commonwealth of Massachusetts
City/Town of
)F"P 0 0
System Pumping
-Record
Form 4
DEP has provided this form'for use4by local Boards of Health. Other forms may be'used, 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 g)right!6d&e:_'qto'u Left/
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address
be- C1. Ll\,r\' P
Cityfrown State Zip Code
2. System Owner: v\"e
Name
Address(if different from location)
city/Town statd, Z�Code
Telephone Number
B. Pumping Rqcord
ID
at—i
1. Date of Pumping ;2. �Q"untity Pumped:
Date Gallons
epr
3. Type-of system: ❑ Cesspool(s) Ic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [3114o If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6.. System Pumped By:
Nell.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati n- re contents were disposed:
Lowell Waste Water
A -BZ63
I
-eignWe 9t Haule Date
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