HomeMy WebLinkAboutSeptic Pumping Slip - 186 INGALLS STREET 12/28/2016 Commonwealth of Massachusetts 17ZECIENED
C4/Town of .
° S /item Pumping.Record � xV Gv �i ;t�r-,, i�a���IX-Ni..
ay
Farm 4
DEP has provided this form for use-by focal Boards of Health. Other form's maybe`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 submitted to
the local Board of Health or other approving authority.
. A. Facility Information
1. System Location: Left/Right front of hou , Peinigg. Right i of house Left/right side of house, Left/
Right side of building, /Right front of b 1 deft/Ri rear of building, Under deck
9 9 9 9
Address •
C"ivTown State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town ' state. 1 Zip Cod ;
Telephone Number
r
1
.B. Pumping tRacord
1. Date of Pumping crate 2. Quantity Pumped: Gallons
3. Type-of system. 0 Cesspool(s) 13,Se ict Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee'Filter present? es If yes, was it cleaned? es ❑ No,
5. Condition of System:
6. System Pumped By:
Nell.Bateson F6821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lo tt�lrwl re contents were disposed.
C S. Lowell Waste Water
Sign gt
a Hbul Date
t5form4.doc-06/03 System Pumping Record•Page 9 of 1