HomeMy WebLinkAboutSeptic Pumping Slip - 174 BRADFORD STREET 8/12/2016 Commonwealth of Massachusetts
City/To
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4
System Pumping-Record
Form 4 AUU ° " ?01'6
DEP has provided this form for userby local Boards of Health. other forms mar� pkbuk the Q r
information-must be substantially the same as that provided here. Before using. is forms, 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 franc of lions e 1 dig reaf hawse,Ieft!right side of house, Left
Right side of building, Left/RigfSt front of bull tdng,Left!R gf building, Under deck
Address
t
City/Town State Zip Code
2. System Owner. �-
Name.
Address(if different from location)
Cityf•rown ' State Z0,0ode
Telephone Number J
.B. Pumping R mcord
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
i
3. Type-of system: ❑ Cesspool(s) - pt c Tank ❑ Tight Tank ,
❑ other(describe):
4. Effluent Tee Filter present? ❑ Yes a o If yes, was it cleaned? ❑ Yes ❑ No,
S. Condition of Syste
�_v °' 7 elLj—I--
6. System Pumped By:
Nell.Bate ibn ' F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Loca re contents were disposed:
Lowell Waste Water
Signitu I fe it Htaule Date
t5form4.doo•08/03 System Pumping Record•Page 9 of 1