HomeMy WebLinkAboutSeptic Pumping Slip - 75 HAY MEADOW ROAD 12/17/2015 i
Commonwealth of Massachusetts
City/Town of ,
y• to Pumping. r � %BI
Form 4 ,U vr
DEP has provided this farm for usez 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 forth 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 Id 1 .rfsint of hous* 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
Cityfrown ..... . State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State / 4 Zip Code
Telephone Number
.B. Pumping Racord
1. Date of Pumping pate 2. Quantity Pumped: Gallons y
3. Type stem:
yp y• ❑ Cesspool(s) ' ❑ eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
14,4
6.. System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca'on..kuhere contents were disposed:
G LSQ Lowell Waste Water
w
Sign t e Haule Date {
0arm4.doc-06/03 System Pumping Record•Page 1 of 1