HomeMy WebLinkAboutSeptic Pumping Slip - 49 ORCHARD HILL ROAD 1/25/2016 I
Commonwealth of Massachusetts
i t�/Town of
System s Pumping Record
s.
Form 4
DEP has provided this form'for use=by local Boards of Health. Other forma 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 t
1. System Location: Left/Right front of se Left/Right rear of house, Left/,right side of house, Left/
Right side of building, Left/Right on of building Left/Right rear of building,Under deck
Address 1 c 6
City/Town State Zip Code
2. System Owner: � :. �
C A�a
. IName
Address(if different from location)
City/Town StateZip Coe
Telephone Number
- a`V
B. Pt;mping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons y
3. Type,of system: ❑ Cesspool(s) [3 eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6: System Pumped By:
Nell.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' where contents were disposed:
G L S: Lowell Waste Water
Sigrij a Haule Date
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