HomeMy WebLinkAboutSeptic Pumping Slip - 1451 OSGOOD STREET 5/2/2016 Commonwe'alth of Massachusefts
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Form 4 E�f,?�
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DEP has provided this form for use-by local Boards of Health. Other forms may be used,`�u fheJ'
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. Informatio,n
I. System Location: Left/Right front of douse, Left]Right rear of housi Under e
Y 9 9 �n �a of house;'L-ft/
Right side of building, Left/Right front of building, Left/Right rear of building, deck'...
- Address .- "• "�� �, <:•. ,
Cityrrown State Zip Code
2: System Owner:
Name'
Address(if different from location)
City/Town ' Stater fip Code
Telephone Number J
i
PlalYlpin cord �.
1. Date of Pumping Date 2. Quantity Pumped-
Gallons ;
Cesspool(s)3. Type•of system: p tic 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:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
L S: ' r contents were disposed:
7. Lacationhar _
Lowell Waste Water
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Sign a cf Haule Date
t5form4.doe-06/03 System Pumping Record•Page 1 of 1