HomeMy WebLinkAboutSeptic Pumping Slip - 135 ACADEMY ROAD 11/28/2017 . ' Commonwealth of Massachusetts
CIWTown of
h.
SysPumping.umpi ng.Reacord
Form 4w 'w iw
DEP has provided this formi for use-by local Boards of Health. Other forms m!ay 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 farm they use.The System Pumping Record must be submitted tca
the local Board of Health or other approving authority.
t
A. Facility Information
L � us t
1. System Location: Left/Right front of House, eft! �"h rear of hour , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Riigh r ar cif building, Under deck
Address
357
CfwTown tate Zip Code
1
2. System Owner j") i
Name'
Address(if different from location)
CityTt'own _ � State �A �ip Code ;
f ff
'telephone Number
j
_.,
B. Pumping record �
9. Date of Pumping gate 2. Quantity Pumped: Canons
3. Type s stem: `
Yp Y. ® Cesspool(s) Septic Tank El Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ® Yes ❑ Na
' S. .Condition of System: � ��� • � �� ��
�� � i
6. System Pumped By:
Nell,Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7, rGL
w ere contents-were disposed:
. Lowell Waste Water t
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SigniWe cfMlule Date I
t5form4.doe-06/03 System Pumping Record•Page 1 of 1