HomeMy WebLinkAboutSeptic Pumping Slip - 338 ABBOTT STREET 7/13/2016 Commonwealth f Massachusetts
City/Town of .
System Pumpm§.Record
Form 4
DEP has provided this form for use;by local Boards of Health. Other forms maybe 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
y � g t o pious , L
Right side of but'Idi eWARi/ ��i . deft 1 Right rear of house, Left/right side of house, Left/
1. System Locatia e 1 Ri fro"._
g, g front of building, Left/Right rear of building, Under deck
Address
CityfTown State Zip Code
2. System Owner: F �
Name'
Address(if different from location)
City/Town State "" „�� a 7,1p
Telephone Number
i
. Pumping e%cor
1. Date of Pumping Date 2. Quantity Pumped: Gallons N�
3. T e•of s stem:
Type-of Y. ❑ Cesspool(s) • ❑ eptic Tank El Tight Tank
❑ Other(describe):
4, Effluent Tee Filter present?" ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
6. Condition of System:
6: System Pumped By:
Neil.Bates ri F5621
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lora'on where contents-were disposed:
I AHiaul'e Lowell Waste Water
Date
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