HomeMy WebLinkAboutSeptic Pumping Slip - 500 REA STREET 11/2/2016 Commonwealth of Massachusetts
City/Town of .
SOtem Pumping.Record RECEIVED
Form 4 NOV lb Z016
y
information-provided must be substantially the samelas that provided ere Before � �. the
V �ieck with Y our
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 Mouse, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
P611�� 4�a�
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town ' St
,. — de ;
Telephone Number
ID
r
.B. Pumping Record
� - _40
1, Date of Pumping to 2. Quantity Pumped: Gallons
3. Type-of system. ❑ Cesspool(s) ❑ ptic Tank
❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lo ere contents-were disposed:
L S'. Lowell Waste Wafer
Sign a cf Hwle Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1