HomeMy WebLinkAboutSeptic Pumping Slip - 41 CEDAR LANE 9/30/2015 f
: Commonwealth of Massachusetts
i City/Town of .
System Pumping-Record
Form 4
1
DEP has provided this form far 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
Y 9 . Rte h ear.., .� ..
1. system Location: Left/Right front of hous Le g of hobs , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig r9r of building, Under deck
Address
City[Town State Zip Code
2. System Owner:
Name•
Address(if different from location)
City/Town ' State �ZCade ;
Telephone Number ++
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons t-r
3. Type-of system: ❑ Cesspool(s) aseptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Q o If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of Sy to
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. I-poation-wherp contents-were disposed:
Lowell Waste Water
ff FOA &j6z-a-,
Sign a I HaulerU Date
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