HomeMy WebLinkAboutSeptic Pumping Slip - 74 STONECLEAVE ROAD 10/1/2015 r
Commonwealth of Massachusetts
City/Town of f
S tem Pumping.Record
Y .
` Form 4
DEP has provided this form for uset 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/Right front of house, Left/ t rear of house Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
Address , t
Cityfrown State Zip Code
2. System Owner:
Name*
Address(if different from location)
Cityfrown ' St In ip Code
Telephone Number
B. Pumping Record
s ._... i
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type,of system. ❑ Cesspool(s) ep id Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0°"Igo if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loc•.aatioff pu re contents were disposed:
G LS 1 Lowell Waste Water
hl Mme.
, • 4
Signitife ct Haule Date
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