HomeMy WebLinkAboutSeptic Pumping Slip - 96 SUGARCANE LANE 11/10/2015 _ Commonwealth of Massachusetts
City/Town of
System Pumping-Record
Form
4
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
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 LocationCLef/Right rout of house Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right fron of building, Left/Right rear of building, Under deck
Address
G c"v1
City/Town State Zip Code
2. System Owner.
M
Name
Address(if different from location)
citylrown State Zip Code
os 0 c,
Telephone Number +`f
B. Pumping Record ..
1
1. Date of Pumping Date 2. uantity Pumped:
IS Q
Gallons y
3. Type-of system: ❑ Cesspool(s) t Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No 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. LocatiorLwhere contents-were disposed:
Lowell Waste Water
Sign a H a u I e Date
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