HomeMy WebLinkAboutSeptic Pumping Slip - 455 CHESTNUT STREET 5/1/2017Commonwealth of Massachusetts
City/Town of . •
ystP ping_ "ecord
Fo 4
DEP has provided this form for useby local Boards Of Health4Qther former).* 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 submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left / Right front of house ight f house) Left/ right side of house, Left /
Right side of building, Left / Right frOnt of buildirig, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
SC
State " Zip Code
Name'
Address (if different from location)
City/Town '
ping Recor
1. Date of Pumping
•
Date
3. Type of system': Cesspool(s)
El Other (describe):
4: Effluent Tee Filter present? 0 Yep
. Condition of System:
State
Telephone Number
2. Quan Pumped:
Gallons
eptic Tank El Tight Tank
If yes, was it cleaned? 0 Yes 0 No,
7\c-- ‘A°.•
6: System Pumped By:
Neil Bates -on •
Name
Bateson Enterprises Inc
Company
7. Locatio where contents were disposed:
a S. Lowell Waste Water
F5821
Vehicle License Nu b r
Sign Haule Date
t5forrn4.doo. 06/03
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