HomeMy WebLinkAboutSeptic Pumping Slip - 196 SUMMER STREET 12/28/2016 wealth of Massachusetts RECEIVED
Common
W
Form 4 MA Hl DU,'1,,%R l �'
DEP has provided this forrri for use-by local Boards 6f Health. Other forms maybe bsed,but the
information must be substantially the same as that provided here. Before using.this fora,check with your
local Board of Health to determine the fora they use.The Systern Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location; L� �Me-lgght f house Left/Right rear of house, Left/right side of Douse, Left
f Right side of building, fight frdnt of building, Left/Right rear of building, Under deck
Address
zit / own 1 state Zip code
2. System Owner: `
Name'
Address(if different from location)
City/Town ' State 1 dip ode
Telephone Number `
r
® Pumping Rqcord `
1. Bate of Pumping at 2. Quantity Pumped: �� --_-�-4-
Bate C;allons •
. Type-of system'. ;J Cesspool(s) eptic Tank Tight Tank
0 Other(describe):
4•. Effluent Tee Filter present'? a Ho If yes,was it cleaned? NO,
' 6. Condition of Sy errs:
6. system Plumped 6y:
Nell,Bat ®n F5821
Name Vehicle License Number
Bateon Enterprises Inc,
Company
7. Location W4 re contents were disposed:
Lowell Waste Water
• F
sign a Hilule Date
t5form4.docm 08/03 system Pumping Record Page I of 1