HomeMy WebLinkAboutSeptic Pumping Slip - 340 SUMMER STREET 12/5/2017 : Commonwealth of Massachusetts
CVTown of .
System Pumping.Record
Form 4
DEP has provided this form for use-by local Boards 6f Health. Other farm's 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 farrh they use.The.System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Inform' a#ion
t. System Location: Loft/Right frozit of douse, Left 1 Right rear of house, Lef, r Ight side cf house Left!
Right side of building, Left 1 Right front of building, Left/Right rear of building, n er ec c
Address
City/Town State - Zip Cone
Z. System Owner.
C
Name'
Address(if different from location)
City/rown ' State Zip Code ;
Telephone z�— `z�C��
t e Number �a
.B. Pumping record
1. Date of Pumping — -jZ2. uantity Pumped:t]a aGallons3. Type of.System: ® Cesspooi(s) c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ Na
5. Condition of System:
6: System Pumped By:
Neil.Betesob _ F5821
Name Vehicle License Number
Batesonhte�r rises Inc
Company
7. location where contents-were disposed:
G L Lowell Waste Water
s
Sign Wil HbuI W Date
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