HomeMy WebLinkAboutSeptic Pumping Slip - 15 BRADFORD STREET 9/12/2016 Commonwealth of Massachusetts
City/Town of
System Pumping.Record
. . :k �
Form 4
DEP has provided this form far use by local Boards of Health. Other forms ma� , lj td &t lie
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
I. System Location: Left/Right front of hous Le Righttf6a_:of_iious4;Left I right side of house, Left/
Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck
- Address I r '
. s
Cityfrown state Zip Code
2. System Owner.
Name"
Address(if different from location)
Cityyfrown ` State ZIA Code ;
Telephone Number +
i
.B. Pumping iRecord
1. Date of Pumping date 2, Quantity Pumped:
Gallons 4-r
3. T e•of s stem: `
Type-of y, ❑ Cesspool(s) ' ® Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yop 3' o _ If yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson_Enterprises Inc,
Company
7. Location where contents were disposed:
Lowell Waste Water y
Sign a Haule Date
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