HomeMy WebLinkAboutSeptic Pumping Slip - 261 BRIDGES LANE 12/28/2015 (2) Commonwealth of Massachusetts
ity/Tcn Of
YS
Pumping Record
Form 4
DEP has provided this form for us&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 is a of house, eft/
Right side of building, Left/Right front of building, Left/Right rear of building, Un #rdeek--- -
Address
ci� e . c •
City/Town State Zip Code
r•
2. System Owner.
t10 C
,. ... ...
Name
Address(if different from location)
Citylrown ' State Zip Cade
JA
Telephone Number
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B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons '
3. Type of system: ❑ C spools) eptic Tan ❑ Tight Tank
❑-U her(describe):
4. Effluent Tee Filter resent?
p ❑ Yes ❑ No If yes, was it cleaned? ❑ `l No.
' 5. Condit'
of Sys'em:
4:7
6. Syste Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
L S'. Lowell Waste Water
Sign t e Haule Date
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