HomeMy WebLinkAboutSeptic Pumping Slip - 450 BOSTON STREET 4/24/2018 Commonwealth of Massachusetts
{ C4/Town o .
System Pumping-Record P a
Form 4
��,i� i�(.r ref S'r ii r 1f)'�• i�.
DEP has provided this form for use-by local Boards o'Meaith. other form6 fr`iay'bo'r,ae°o 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€orris they use.The;System Pumping Record must be submitted:to
the local Board of Health or other approving authority.
A. Facility. lntorMatlon _
1. System Location: 1-eft/Right front of house, Left/Right rear of hoes Left rig "side of hou , Left l
Right side of building, Left/Right front of buildirig, Left/Right rear cif i.rl ding, Under ep
Address
City/1 awn state Zip Code
2. System owner:
Name'
Address(if different from location)
CityfTown ' $tatQ�'" (yJ y h ' Code
Telephone Number
Purnping JRpcord �
1. Gate of Pumping Date l 2. Quantity Pumped: ! °
Gallons
3. Type-of system. ® Cesspool(s) epic Tank ❑ Tight Tank
❑ other(describe):
4. Effluent Tee Filter present? ® Yep ® No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: +
PC
6. System Pumped By:
Nell.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location where contents were disposed:
CLS: Lowell Waste Water
Sign a I HiaulerU Bate 1
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