HomeMy WebLinkAboutSeptic Pumping Slip - 120 LIBERTY STREET 6/13/2016 Commonwealth f Massachusetts RECEIVED
C4/Town of
mping. Record
YS
Form 4 OF IT
1V `
� i �i�l l) �>r'Clflr".III
DEP has provided this form for use-by local Boards of Health. Other forms'Ma'y 6e 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 Le /igh fron of house, Left/Right'rear of house, Left/right side of house, Left/
Right side of building, Left/Right fronF6fbuilding, Left/Right rear of building, Under deck
'
m.
Address
.m.e PA
City/Town
State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town ' Star"")
Telephone Number
-&—pumping Rpcord .
1. Date of Pumping
ti Pumped:
Date 2. Quantity P Gallons ,
3. Type of system: ❑ Cesspool(s) {�""Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [T No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6: System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location-w, re contents-were disposed:
Lowell Waste Water
—h1ja
EipAtu fe 9t Haule date
t5form4.doc®06/08 System Pumping Record•Page 1 of 1