HomeMy WebLinkAboutSeptic Pumping Slip - 258 REA STREET 11/28/2017 Commonwealth of Massachusetts f z ' mm
Cityffown of n; �
Form 4 � `kr
DEP has provided this form for use=by local Boards of Health. other forrnrrzay'be'used,but the 1
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. Informi ation
1. System Locatio �L��t/ igh ont 0�ofsbuildifig,
Left/Right rear of house, Left/right side of house, LeftRight side of bui t I RigY� noLeft/Right rear of building, Under deck i
j
Address �" ., �✓,t...-�"` � �_ _ :-•���� ,rv. �
Citylrown state Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityltawn '. State���„✓ C�"ip�ode
A
"telephone Number
r
it
i
P'umpingl.Rpcorrd
1. Cate of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: 0 Cesspool(s) Septic Tank ® Tight Tanis
Ej Other(describe):
4. Effluent Tee Filter present? es ® No If yes, was it cleaned? [3-Ye--s- No,
5. Condition of System:
6., System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
1
7. Lo titin*here contents-were disposed:
CLS; Lowell Waste Water
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P-1 0 LC 1
Sign t e It HauleV Date
t5famt4.doo*06/03 System Pumping Record•Page 9 of 1
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