HomeMy WebLinkAboutSeptic Pumping Slip - 260 BRADFORD STREET 5/26/2016 : Commonwealth of Massachusetts
= City/Town of .
System Pumping-Record
Form 4
DEP has provided this form for userby 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, a Rig rear f hou , Left/right side of house, Left/
Right side of building, Left/Right front of bull elhga, Left rear of building, Under deck
Address ^��
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State ip de
Telephone Number ;
i
.B. Pumping Record
1. Date of Pumping �Qwuu ty Pu mped:Date Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L5'No 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 fi ere contents-were disposed:
GLS-Q Lowell Waste Water
Sign a HtuleV Date
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