HomeMy WebLinkAboutSeptic Pumping Slip - 63 BRADFORD STREET 10/5/2016 Commonwealth of Massachusetts D
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item �uming. ecard -�
r° Form 4
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DEP has provided this form for use-by local Boards of Health. 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 house, Left/(�14_ er ar o , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citynown ' State / Zip Code
Telephone Number
.B. Pumping JRecord
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. T e,of s stem: `
yp y, ❑ Cesspool(s) - eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep M160 If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System: JVI-C'k
/
6: System Pumped By:
Neil,Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca `vrrwhare contents-were disposed:
GL SQ Lowell Waste Water
Sign a Haul Date
t5fbrm4.doc-06/03 System Pumping Record•Page a of 1