HomeMy WebLinkAboutSeptic Pumping Slip - 90 SPRING HILL ROAD 12/2/2015 ' f
`0 Commonwealth of Massachusetts
= City/Town of .
Y' to m 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 Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address '�� 3 V� A4
Citylrown State Zip Code
2. System Owner:
Name' `�
a�r.T,
Address(if different from location)
Citylrown ' State Zip
Telephone Number
3 1
1
B. Pumping Record
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? YerC3 No If yes, was it cleaned? ❑r'Yes ❑ No,
5. Condition of System-
. .
6.. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L Lowell Waste Water
ff reSA
.. �
Sign a I Haule Date
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