HomeMy WebLinkAboutSeptic Pumping Slip - 500 REA STREET 12/4/2017 Commonwealth Of Massachusetts M C ;�1 E
Clty/Town of
SOtenn Pumping.Record l
Form 4 TOVW1 ff �vffc11 400VER �
i�:.ALJ[1 L PARTMEP4T
DEP has provided this form for use.by local 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 forth they use. The System Pumping Record must be submitted tc)
the local Board of Health or other approving authority.
t
A. Facility InforMation
1. System Location; Loft i t fr no tt of ho sir, 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
Citylrown State Zip Code
2; System Owner:
- U
Name'
Address(if different from location)
Cityrrown ' State Zi Cod
de
e
Telephone Number '
Pumping Record
1. gate of Pumping nate 2. Quan#ity Pumped; ;
Gallons A—
3. 'Type-of system: Ej Cesspool(s) 01.1eptic Tank Tight Tank
® Other(describe).
4.. Effluent Tee Filter present? El Yes at o If yes, was it cleaned? Yes No,
5. Condition ofSystem,A 1 / CLLQ
6. System Pumped By:
1
NellBateson�' � � F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. LocatiWel
e contents were disposed:
.L Lowell Waste Water
_ J
Sign a Haui-PAW Ba
Date
t5form4.doc-06/08 System Pumping Record•Page 1 of f
r�