HomeMy WebLinkAboutSeptic Pumping Slip - 1659 OSGOOD STREET 10/18/2016 Commonwealth of Massachusetts �
City/Town of
i w /
System Pumping-Record ``'
Form 4 h .
r
4
DEP has provided this form for use-by local Boards of Health. Other farms may be'used, but the
lnformation 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/Right rear of house, Left/r ht�'ide of h❑use" eft/
Right side of building, Left/Right front of building, Left/Right rear of building, Un er ec
Address
City/Town A State Zip Code
2. System Owner. -Tz
L/V\ oe:�
Name.
Address(if different from location)
City/rown
Stater Zip Code
S�. cso
Telephone Number
r
.B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped:
r
Gallons
3. Type'of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent flee Filter present? ❑ Yep 04 If yes, was it cleaned? ❑ Yes ❑ No
' S. Condition of System:
I� °�y J `❑
6. System Pumped By:
Neil,Bateson F5821
Name Vehicle License Number
Bateson Enterprises inc-
Company
7. Loc contents were disposed:
Lowell Waste Water
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Sign a I Haule Date
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