HomeMy WebLinkAboutSeptic Pumping Slip - 68 CRICKET LANE 12/17/2015 Commonwealth of Massachusetts
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S stern Pumping-Record ot,r„
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Form 4 1
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 rr%ght side of house, :eft/
Right side of building, Left/Right front of building, Left/Right rear of building, Under decd' µ µ
Address
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Citylrown state Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityrrown State Zip Cade
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Telephone Numberw
B. Pumping ,record
1. Date of Pumping pate 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0-Iqo If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System•
6: System Pumped By:
Neil.Bates ri F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
_L S Lowell Waste Water
( 1 ��.
Sign a I Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1