HomeMy WebLinkAboutSeptic Pumping Slip - 140 BRADFORD STREET 6/28/2016 Commonwealth of Massachusetts
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ytm Pumping-Record
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DEP has provided this farm 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. Facill.ty. In r i
1. S y stem Locatio . Le %RI g h rc,,t„of
s�`� Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town state zip Code
2. System Owner:
„e
Name
Address(if different from location)
Ci lTown '
ty - State . � i �C,o
Telephone Number �1
i
. Pumping J Record
1. Date of Pumping sate 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yep ❑' o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of ste
6.- System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatign40 bM`contents-were disposed:
Lowell Waste Water
411 OA- 'Bz6a-,,e�
n,
c l
Sign a I Haule Date
t5form4.doc•08103 System Pumping Record•Page 1 of 4