HomeMy WebLinkAboutSeptic Pumping Slip - 338 BERRY STREET 12/17/2015 Commonwealth of thus tt
• ity/Town of .
y' tem Pumping-Record
s•`
Form 4 1
DEP has provided this form for useFb local Boards of Health. Other forms ma tie use but th
P Y Y
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
I. System Location: Left/Right front of house, Left/Right rear of housq, b�#✓right Ide 6bf ho§p)Left/
Right side of building, Left/Right front of building, Left/Right rear®f u5 i ding, Under deck
Address
Civrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityrrown ' Stag d°� —Zip Code
Telephone Number
3
.B. Pumping Rpcord
1. Date of Pumping Date 2. Quantity-Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) ET 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.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lora' iv re contents-were disposed:
L S. Lowell Waste Water
Sign a qf Haule Date
t5form4.doc•08/03 System Pumping Record•Page 1 of 1