HomeMy WebLinkAboutSeptic Pumping Slip - 102 SPRING HILL ROAD 12/17/2015 Commonwealth of Massachusetts
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City/Town of
•2 S ' tem Pumping-Record
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TUM,q o[� /�J,HOIER
Form 4 HEALI HI 1�11
DEP has provided this form for use-by local Boards of Health. Other forms may be'used, b'but the
information-must be substantially the tame as that provided here. Before using.this form., check with your
loca'I 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 9CFU:dM rear of ho'*�Left right side of house, Left
1.
Right side of building, Left Right front of building, Left iigfit—rear of building, Under deck
Address
_-x
Citynown � state Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityfrown Stat Z* Code
Telephone Number
B. Pumping Record
I Date of Pumping 2. Qu6ntity Pumped:
Tate Gallons
3. Type-of system" F-1 Cesspool(s) G—Septic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? _Y_e No If yes, was it cleaned? []--Yes [j No,
5. Condition of System:
CX
6. System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. LocafionXhere contents-were disposed:
Lowell Waste Water
I
Sign itu.fe 9f HauleV Date
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