HomeMy WebLinkAboutSeptic Pumping Slip - 370 SUMMER STREET 10/29/2016 RECEIVED
Commonwealth of Massachusetts
NOV 11 1/,016
City/Town of
System Pumping.recordALTH L' iest
f
Form 4
y.
DEP has provided this farm 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/Right rear of hour C'ff` igh sid of house Left/
Right side of building, Left/Right front of building, Left/Right rear o ui ding, Un er k'�
Address
Cityrrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown ` State Zip Code
Telephone Number f
r
.B. Pumping Record
1. Date of Pumping bate 2. Quantity Pumped: Gallons
3. Type�of system: ❑ Cesspool(s) ❑ Septic Tank ❑ Tight Tank i.
Cher(describe):
4. Effluent Tee Filter present? ❑ Yep ❑ No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: _
6; System Pumped By:
Neil,Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio here contents were disposed:
6LS'k Lowell Waste Water
Slgngq,e qt Hauls Date
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