HomeMy WebLinkAboutSeptic Pumping Slip - 24 FARNUM STREET 8/11/2016 : Commonwealth of Massachusetts
RECEIVED
CRY/Town of
h.
System Pumping-Record AUG 15' 1(
Form 4
DEP has provided this form far use,by local Boards of Hea k i. 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 hour Le -dig al off ht�u , Left/r titidf house, Left/
Right side of building Left/Rigfit front of building, Left I�1g r ear of buildin Under k
Address
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town ' State ZIP Code ;
Telephone Number
•a 1
i
.B. Pumping Record
R7-
1, Date of Pumping ante 2. Quantity Pumped: Gallons
3. T y pe-of s stem Cesspool(s)oof(s) p tTc ank
F1 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 040 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle license Number
Bateson Enterprises Inc
Company
7, Lo ti here contents-were disposed:
G L.
S: Lowell Waste Water
-P/ aSA
Sign a I Haule Date
t5form4.doo•06/03 System Pumping Record•Page 1 of 1