HomeMy WebLinkAboutSeptic Pumping Slip - 270 SOUTH BRADFORD STREET 8/23/2017 Commonwealth of Massachusetts
CitY/Town of
. C
Sy/ tem Pumping.Record JiN4Ov NORi"
"CkC� �
Form 4
1
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 farm,check with your t
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
i. System Location{ (6jiAlg ro of house a Left/Right rear of house, Left/right side of house, Left/
Right side of build g, Left I Ri ion at�buuildirig, Left/Right rear of building, Under deck
9 9 g
Address
City/Town State Zip Code
2. System owner.
Name'
Address(if different from location)
cityfrown ' State i Code
Telephone Number
Pumping Recorc!
1. Date of Pumping 2Crtity Pumped: r----=�
DateGallons
3. Type•of system: El Cesspool(s) ®��epfic'�Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Fitterresent?
p Yes o If yes, was it cleaned? ® Yes ❑ No,
5. Condition of System
.�' -�`�"1"`r`''C,;C--��
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. 1-05cafi- where contents were disposed:
CLS: �~ ` Lowell Waste Water
Sjgn"e-fH—tiule(j Date
15form4.doc-06/03 System Pumping Record•Page 1 of i
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