HomeMy WebLinkAboutSeptic Pumping Slip - 438 SUMMER STREET 6/28/2017 :. Commonwtttth of Massachusetts
.Citk/Town of . RECEIVED
System P•umpin§.Record0 5
.
Form 4
VM q NORIR X14DOVER
I pII),,,RTMr,_N
DEP has,provided this form for use-by local Boards of Health. Other forms mapVe used, but the
information,must be substantially the same as that provided here. Before using.thls 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. Informa tion
I. System Location: Left/Right front of haus e
y g gh ear of s , Left/right side of house, Left
Right side of building, Left I Riglit front of but frig, Left I Right rear of building, Under deck
Address
citylrown State Zip code
2'. System Owner:
Name'
Address(if different from location) ,
cityfrown State' Zip Code
} al
`•--d
Telephone Number
.B. Pumping Ripcord
1, Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Lia If yes, was it cleaned? ❑ Yes ❑ Na
' S. Condition of System: _ /
01
1
6, System Pumped By:
Neil.Bateson.- F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
GLS: Lowell Waste Water
s
Si—gni HWwU Date
iformCdoc+06/03 System Pumping Record+Page 1 of 1