HomeMy WebLinkAboutSeptic Pumping Slip - 15 BRADFORD STREET 9/7/2017 Commonwealth of Massachusetts
RECEIVED
CitY/Town of .
tJ1
System Pumping.Record
Form 4 F�0�aTg At4DD
HCA0 M TM
3
DEP has provided this form for use-by focal Boards of Health. other forms maybe*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 t0 1
the local Board of Health or other approving authority.
A. Facility. Information
1, System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear cif building, Under deck
Address ,
CRY/Town state Zip Code
2. System Owner.
Marne'
Address(if different from location)
cityrrown State Lf
Telephone Number
. Pumping JRecord
1. Date of PumpingDate 2. Quantity Pumped: Gallons
3. Type-of systerri: ® Cesspool(s) eptic Tank ❑ Tight Tank
® Other(describe):
4.. Effluent Tee Filter present.? ❑ Yes o If yes, was it cleaned? ❑ Yes ® No,
5. Condition of System: +
6. System Pumped By:
Nell.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locoanwhere contents-were disposed:
CLLowell Waste Water
Sign a Haute Date
t5f6rm4.doe-06/08 System Pumping Record•Page 1 of 1
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