HomeMy WebLinkAboutSeptic Pumping Slip - 25 HOLLOW TREE LANE 10/15/2015 l
Commonwealth of Massachusetts .
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City/Town of :°; a pL `.
k
System Pumping-Record
Form 4 ��� ���v2pNp
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 r
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. S y s•tem Location. Ce'/,�Ri g fr nt
of housed Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/ ightfront of building, Left/Right rear of building, Under deck
Address Ll
._.
City/Town State Zip Code
2. System Owner:
Name*
Address(if different from location)
CitylTown ' .. State � � Zip Code '
Telephone Number F w
B. Pumping Record ._._
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) EJ—Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep ❑''No If yes, was it cleaned? ❑ Yes ❑ No 1
5. Condition of System
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location ere contents-were disposed:
Lowell Waste Water
a
-dig—nitu a Haule date
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