HomeMy WebLinkAboutSeptic Pumping Slip - 230 GRANVILLE LANE 11/12/2016 Commonwealth of Massachusetts
4 City/Town of . RECEIVED
System Pumping-Record �Jo .p tj zt
Form 4
TOWN �t4UR l H AWOVE
HEALTH DEPA TMUJ
DEP has provided this form for use�by local Boards of Health. Other forms maybe used, but the
information trust 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 douse, 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 (7 r C�y1 UE h
City/Town State
Zip Code
2. System Owner.
Name'
Address(if different from location)
city/Town ' State Zip Code
UgC, U
Telephone Number
i
F
.B. Pumping kecord
0 - U - 116 av
1. Date of Pumping sate 2. Quantity Pumped: Gallons w�`
3. Type-of system: ❑ Cesspool(s) Eg Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of system:
6: System Pumped By:
Nell.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location where contents were disposed:
GLS-p Lowell Waste Water
Sign a Haule Date
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