HomeMy WebLinkAboutSeptic Pumping Slip - 426 SUMMER STREET 12/5/2017 : Commonwealth of Massachusetts
y City/Town o .
System Pumping.Record
Form 4
DEP has provided this farm for use-by lova[Boards of Health. Other€arm'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€grin they use..The.System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility, inform' ation
1. System Location: Left/Right front of douse, Left 1 i t rear of hous , Left./right side of house, Left I
Right side of building, Lett 1 Right front of buildirig, LOW Rig rear of building, Under deck
Address 1 4 a c ._ u v/k U1 J- � �
CWrown rG moi' State - Zip code
2. System Owner.
Name'
Address(if different from location)
City/Town >� Z�® i� d� ;
i `ry
Telephone Number
.B. Pumping Record `
1. Date of Pumping bate 2. Quantity Pumped: Gallons r�
3. Type-of system: ® Cesspool(s) eptic Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes 0,1510 If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of Syr to
6. System Pumped By:
Neil Batesbn F6821
Name Vehicle License Number
Bateson Enterprises Ing p
Company e
p
7. Locatiti re contents were disposed:
GLS Lowell Waste Water
�- d-5-- c 7
. F
sign a Haul Date
WormUov 06103 System Pumping Record•Page 1 of 1