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HomeMy WebLinkAboutSeptic Pumping Slip - 455 CHESTNUT STREET 5/17/2016 : Commonwealth of Massachusetts = City/Town of . System Pumping-Record Form 4 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, eft Righ ear f house Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/ffig-hMarblbuilding, Under deck Address Ly_S S Citylrown State Zip Code 2. System Owner. f CZV \ Name' Address(if different from location) City/Town State- Zip Code ; Telephone Number _ Er .B. Pumping Record 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ©-Nb- If yes, was it cleaned? ❑ Yes ❑ No, 5. Condition of System: 6: System Pumped By: Neil.Bateson - F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Lo # h ontnts-were disposed: L S eLowell Waste Water (k° S F Date t5form4.doc•06103 System Pumping Record•Page 1 of 1