HomeMy WebLinkAboutSeptic Pumping Slip - 322 BOSTON STREET 1/26/2012 Commonwealth Of Massachusetts
City/Town of
System Pumping ecord
Form 4
DEP has provided this form for use by local Boards o t e used, but the
information must be substantial) the same as that r vi " "�" is form, check with your
local Board of Health to determine the form they use. W'Syst tn-Pu pi'rrg-R rd must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house ef(LRi �� o u
Right side of building, Left/Right front of buil ng, Left/Right rear o Left/right side of house, Left/
y g Ke ghjrear_f h
of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zi Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date Z Quantity Pumped: canons
3. Type of system: ❑ Cesspool(s) a-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes ❑ No If yes, was it cleaned? D-°°'des❑ No
5. Condition of Syste :
6. System Pumped �
a:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G L S.P Lowell Waste Water
r
Sign A to a I Haule at
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