HomeMy WebLinkAboutSeptic Pumping Slip - 163 SUMMER STREET 6/5/2017 Commonwealth f Massachusetts RECEIVED
City/Town of JL4,1 H17
• TOWN OF W�[H AN[)O :
Form 4
HEALTH DERA TMENT
DEP has provided this form for use-by local Boards 6f Health. Other forms rnay'be'used,but the
information must be substantially the tame as that provided here. Before using.this forme,Check with your
loca'i Board of Health to determine the forts they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facill.ty. Information.
1. System Location: Left/Right front of Mouse, e.•., .. i d out Left. right aids of house, Left/
°g Right side of building, Left I Right front of building, Le ig Mr o6'tuilding, Under deck
Address
City/Town State Zip Code
2. System Owner:
Address(if different from location)
City/7'own ` state .., Zip Code
f Telephone Number ` r
t
Pumpling Rpcord
f. Date of Pumping ��te l . QuantitywPumped,
Gallons
3. Type-of system: Cesspool(s) ptic Tank D Tight Tank
Other(describe):
4. Effluent Tee Filter present? E Yep o If yes, was it cleaned? E Yes D No
. Condition of Syste
r
6. System Pumped By,
Nell.Bateson F5821!Name Vehicle License Number
Bateson Enterprises lnc
Company
7. jS19ne
It are contents-were disposed:
GLS.)? Lowell Waste Water
Hhule Mete
t5forrn4.doG-06/03 System lumping Record mega 1 of I