HomeMy WebLinkAboutSeptic Pumping Slip - 186 BRADFORD STREET 4/24/2018 Commonwelalthf Massachusefts ,
City/Town of
Form 4
DEP ha'provided this form'for use=by local Boards 6f Health. Other forms may be`used,but the
'
information-must be substantially the me 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 to
the local Board of Health or other approving authority.
A. FacIlRy. information
1. System Location: Left/Right front pf house, Left ighIt rear of hou eft/right side of house, Left
Right side of building, Left/Right front of building,e9f/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner:
Name'
Address Of different from location)
Cityfrown - State Zip Code
Telephone umber +'
. Pumping
1. Cate of Pumping aJ — �- Quantity Pumped: Gallons
3. Type-of system: Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present.? ® Yes No If yes, was it cleaned? ® Yes ❑ Na
S. Condition of System:
r .
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. L . ww, ere content&were disposed:
Q L S. Lowell Waste Water
F
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t fbrmCdow 08/03 System Pumping Record.page 1 of 1