HomeMy WebLinkAboutSeptic Pumping Slip - 338 BERRY STREET 12/13/2016 Commonwealth of Massachusetts
M. Y
City/Town of RECEIVED
System Pumping-Record 01 �1 X01
Form 4
DEP has provided this forfri 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 submltted to
the local Board of Health or other approving authority.
A. Facility. Information
j 1. System Location: Left/Right front of house, Left J Right rear of house, �) righi silo of house,;Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under_dec`k`
address
CWrown State Zip Code
2. System Owner: 4 ,
Name'
Address(if different from location)
City/Town ' State d
y Telephone Number
i
.B. Pumpiiing Record
1. Date of Pumping gate 2. Quantity Pumped: .m. '
Lallans
3. Type-of system: [] Cesspool(s) [:5_''9eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: r
6: System Pumped By:
Nell.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
'L S:. Lowell Waste Water
Sign a Haule Date
t5form4.doc,-06/03 System Pumping Record•Page 1 of 1