HomeMy WebLinkAboutSeptic Pumping Slip - 285 REA STREET 11/7/2016 : ` , Commonwealth of Massachusetts
• City/Town of RECEIVED
4. System Pumping-Record
Form 4 NOV . 016
DEP has provided this form far use:by local Boards of Health. Other forms m i c:�i=�`q PtA r al-
infarmation must be substantially the same as that provided here. Before usinis 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�M*ag, Rlg and of hour Left/Right rear of house, Left/right side of house, Left/
Right side of faun Left/Right front of building, Left/Right rear of building, Under deck
Address ...
City/Town State Zip Cotle
2. System Owner:
Name'
Address(if different from location)
cityfrown - stat Zip Code
Telephone Number
.B. Pumping Record � tt
1. Date of Pumping pate 2. Quantity Pumped: Gallons ``—`
3. Type-of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? [ e- ❑ No if yes, was it cleaned? -0 No,
' 5. Condition of Syste ,•
6. System Pumped By:
Neil.Batesion F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loca ' 11 are contents were disposed:
C L S'Q Lowell Waste Water
SignAtu,fe 9f Haule Date
t5form4.doc•06/03 system Pumping Record•Peg*a 1 of 1