HomeMy WebLinkAboutSeptic Pumping Slip - 408 BOSTON STREET 11/17/2017 i Commonwealth of Massachusetts
RECEIVED
i
C4/Town of .
Sy tem Pumping.Record
TOWN N GAG NOM H MDOVE
Form 4i ;J�LTH 0Ef-1 RTM0'4'F
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 forrh they use.The;System Pumping Record must be submitted to t
the local Board of Health or other approving authority.
A. Facility. Inform' ation
9. System Location: Left/Right front of House, ei Righ Cepitolhous , Left/right side of house, Left
Right side of building, Left C Right front of buil irig, Left/ a of building, Under deck
Address
City(Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town state.
C' C j Zip„Code ;
Telephone Number ;
e Pumping
1. Date of Pumping gate 2. Quantity Pumped:
Gallons ;�•—�
3. Type-of system: E Cesspool(s) eptie Tank El Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes 10-N� If yes, was it cleaned? Yes ® No
5. Condition of System:
0,(, A
6. System Pumped By:
Melt.Bateson F5821
Name vehicle License Number
Bateson Enterprises Inc-
Company
7. Locab were contents-were disposed: 1
�L S: Lowell Waste Water
sign a Haule Date F
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