HomeMy WebLinkAboutSeptic Pumping Slip - 71 WILLOW RIDGE ROAD 9/28/2015 Commonwealth of Massachusetts
City/Town of .
yitem Pu pin c rd
Form 4
DEP has provided this form for usezby 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: a ig i o t of housLeft/Right rear of house, Left/right side of house, Left/
Right side of buil ' g, Left/Right ron o ldir ig, Left/Right rear of building, Under deck
Address CYA
City/Town state Zip Code
2. System Owner.
V� vi ,'l r� .
Name'
Address(if different from location)
City/Town State Zip f ;
Telephone Number rr"
B. Pumping JRpcord .
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ If yes, was it cleaned? ❑ Yes ❑ No
" 5. Condition stern:
6. System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo tion� a contents-were disposed:
Lowell Waste Water
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f
-gignA a 9t Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1