HomeMy WebLinkAboutSeptic Pumping Slip - 128 MILL ROAD 9/28/2016 Commonwealth of Massachusetts
City/Town of
W° S stern Pum in ' .Record
Form 4
DEP has provided this form for use.-by local Boards of Health. Other forms
maybe 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 farm 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/Right rear of house, Left/ g f side off hour .eft/
Right side of building, Left/Right front of building, Left/Right rear of building, Under eck
Address ,
cvrown State Zip Code
2. System Owner " j .lk . C Cl\ '4_.
Name'
Address(if different from location)
city/Town ` '. State
F
Telephone Number
i
.r
.B, Pumping record
1. Date of Pumping 17ate 2. Quantity Pumped:
Gallons
3. Type•of system: ❑ Cesspool(s) eptle Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System:
6.- System Pumped By:
Nell.Bateson F5821
Name Vehicle license Number
Bateson Enterprises Inc'
Company
7. Lo a ,here contents-were disposed:
G S: Lowell Waste Water
Sign Vtu AaUHiauletj Date
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