HomeMy WebLinkAboutSeptic Pumping Slip - 962 TURNPIKE STREET 11/16/2016 Commonwealth of Massachusetts
RECEIVED
City/Town of .
NOV
System Pumping-Record
x` Form 4
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HE ,LT-�D i i �1 l T
DEP has provided this form for use*by local Boards of Health. Other forms may be'used, but the
lnfbrmation must be substantially the same as that provided here. Before using.this form, check with 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
I. System Location: Left/Right front of house, Left rah ret a Left/right side of house, Left/
Right side of building, Left/Right front of building,eft/Right rear of building, Under deck
Address
k U
�.
CVTown State Zip Code
2. System Owner.
oAe.
Name
Address(if different from location)
City/Town Stat__"`��y � ip Gods
Telephone Number
3 d
.B. Pamping record
7. Date of Pumping U �
�mm�
p g umpe
2• Quantity Pd:
date Gallons
3. Type-of s
yp stem:y. ❑ Cesspool(s) ' Q.,,.Se Ic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep o 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. Location ere contents were disposed:
IL S•w� Lowell Waste Water
. Jr rr -
t �l
Sign a Haule Date
t5f6rm4.do(.-06/03 System Pumping Record•Page 1 of 1