HomeMy WebLinkAboutSeptic Pumping Slip - 411 SUMMER STREET 9/7/2017 Commonwealth of Massachusetts RECEIVED
.City/Town of .
�. 7
Sy:stem Pumping.Record
Form 4 160 OF t1Cll TVj At4DOVER, f
r
DEP has provided this farm 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 form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information,
I. System Location: Left/Right front of Mouse, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
cityrrown state Zip Code
2. System owner.
Name'
Address(if different from location)
City/Town ' Wat Zip Code
r
Telephone Number
. P'um'ping Record
-17
9. Date of Pumping gate 2. Quantity Pumped:
Gallons i------�
3. Type-of system: ❑ Cesspool(s) ® "e _ptic Tank ❑ Tight Tank i
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ Not
' 5. Condition of Sys
6. System Pumped By:
Feil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca`on ere contents-were disposed:
CLS: Lowell Waste Water
Sign t e I Haul Date
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