HomeMy WebLinkAboutSeptic Pumping Slip - 162 ABBOTT STREET 8/24/2016 Commonwealth of Massachusetts
City/Town of �; e
System Pumping,Record µ 1�OF otRp A P �
Form 4 ���p , L(tj � �t
DEP has provided this form far use=by local Boards of Health. Other form's may *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 house, Left iglu ear of housy , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
. Address
Cityrrown State Zip Coale
2. System Owner.
Name'
Address(if different from location)
City/Town State ,. Zi Code
Telephone Number
a
.B. Pumping Record
m.
1. Date of Pumping pate 2. Quantity Pumped: Canons r
3. Type-of system: ❑ Ce ool(s) [ eptic Tank ❑ Tight Tank
-t a..,
Other(describe):
4. Effluent Tee Filter present? ❑ Yee ❑ No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: --
6: System Pumped By:
Neil.Batesbn - F5821
Name Vehicle License Number
Batesan Ehterprises Inc
Company
7. Lo ti6rrw �,r contents were disposed:
G L Lowell Waste Water
SignAW to 9t Haule Date G✓ {
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