HomeMy WebLinkAboutSeptic Pumping Slip - 465 CHESTNUT STREET 10/20/2016 Commonwealth of Massachusefts
x
City/Town of
System Pumping.. Record
Form 4
DEP has provided this form far use-by local Boards of Health. Other forms may be•used, but the F� '
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 J 1igh ar f ho su , Left/right side of house, Left/
Right side of building, Left/Right front of but I ig, Left liigg rear o buifdin , Under deck
g
Address
City/Town State Zip Code
2. System Owner:
Name
f Address(if different from location)
Y Cityfrown ' Stat • C" Zip 090e
Telephone Number ;r
r
B. Pumps g, cord
1. date of Pumping crate 2. Quantity Pumped: .. J
Gallons
3. Type-of system: ❑ Cesspool(s) ❑ Septic Tank I Tigh Tank
ther(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No,
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:
'`S. Lowell Waste Water
I ff TOA
Signitu a Houle Date
t5farm4.doc-06/03 System Pumping Record•Page 1 of 1