HomeMy WebLinkAboutSeptic Pumping Slip - 150 BRADFORD STREET 10/21/2016 : Commonwealth of Massachusetts
w City/Town of . OECEIVED
System Pumping-Record
Form 4 C „1
TOKW OF
DEP has provided this form for use-by local Boards of Health. Other forms ma t�� bfAt�y
information,must be substantially the same as that provided here. Before using.. is
fa frith your
focal 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
y (. Left/R~(fit front of "Left/Right rear of house, Left/right side of house, Left/
1� Right side of building, Ri h roll bf House,
g, g building, Left/Right rear of building, Under deck
_ Address
City/Town State Zip Code
2. System Owner. -r
Name
Address(if different from location)
Citylrown State- Zip Code ;
Telephone Number i
.B• Pumping Record
1. Date of Pumping Da Quantity Pumped:
Gallons .
3. Type-of system. ❑ Cesspool(s) b7septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6; System Pumped By:
Neil Batesan - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Laca er `Where contents-were disposed:
Lowell Waste Water
LP/ aSA 16
sig—nitu AqVHauleV Date —'
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