HomeMy WebLinkAboutSeptic Pumping Slip - 145 COLONIAL AVENUE 8/21/2017 Commonwealth of Massachusetts RECEE
M Cityffown of AUG1 1
SOtem Pumping.Record TOM OF NOM MDO
y
Form 4 ti TH IMPARTMENT
DEP has provided this form far use-by local Boards of Health. other forms may 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 forrh 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 l Right front cf Mouse, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left I Right front of building, Left I Right rear of building, Under deck
Address
City/Town State Zip Code
2. System owner: �`�,� -_� • G--��-c,.��
Name'
Address(if different from location)
City/Town State � .. � _p Code
Telephone plumber
CS
. Pumping Rpcotrd
—47
1. Date of Pumping sate 2• Quantity Pumped: Gallons +
3. Type-of system: ® Cesspool(s) eptic-ank ❑ Tight Tank
❑ Other(describe):
resent?
4. Effluent Tee Fitter
p ❑ Yes o � ~ if yes, was it cleaned? ❑ Yes ElNo,
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
^� S: Lowell Waste Water
1
Sign e. Haul Date
0=4.doc•08/03 System Pumping Record•Page 1 of 1
rte,