HomeMy WebLinkAboutSeptic Pumping Slip - 365 BOSTON STREET 8/23/2017 : C Commonwealth of MassachusettsRECEIVED
City/Town of
System P'-umplipg.Record 100 c t " "
jMW
DEPW
Form 4
DEP has provided this form for 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 forth they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facil%ty Informiation
1. System Location: Left/Right front of Mouse, Left/Right rear of house, Lefti ht side of house eft
Right side of building, Left/Right front of building, Left/Right rear of building, n er deck
Address ,- - i d
Citylrown State Zip Code
2. System C7wner:
� � -( _ v
,�,A
Name.
Address(if different from location)
Cityrrown Stater de
"telephone Number E'"
.B. Pumping Record
9. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ® Cesspool(s) epric Tank El Tight Tank
rl Other(describe): t
4.. Effluent Tee Filter present? a'Yees No If yes, was it cleaned? ED-Ye__s____. No. t
5. Condition of Sysre :
6. System Pumped By:
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
GIL S,
it Q Lowell Waste Water
Sl nAtuhe 9t Houle Date
t form4.dov 06/03 System Pumping Record•Page 1 of 1