HomeMy WebLinkAboutSeptic Pumping Slip - 103 BRADFORD STREET 7/2/2018 Commonwealth Of Massachusetts RECEIVED'
City/Town o
SyMem Pumping.Record
Form 4 TOWN I:^��pPipp+�G^^71IRTk�yANR_4p�kVtt^ER
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IABP ha'provided this forrri 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 fora,check with your
local Board of Health to determine the forrh they use.The System pumping Record must be submitted to
the local Board of Health or other approving authority.
A. ill , tl r
1. System Location: Left/Right front of house, Left/Right rear of hour. , Left rig .—ry house,,,ileft
Right side of building, Left/Right front of building, Left/Right rear of ing, Under deck
Address -,
Cit rowown State Zip Code
2. System Owner: J'
Name'
Address(if dirrerent from location)
Cityr/Yown StateCC> " ;11P
"telephone Number
t
'
1. bate of Dumping Date 2. Quantity Pumped:
Daltons
3. Type-of system: El Cesspools) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes ffNo If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition Pf stem:
6: System Pumped By:
Nell.Bateson F6821
Mame Vehicle Licerse Number
Bateson Enterprises Ina
Company
7, Lo re contents•were disposed:
M L S: Lowell Waste Water
C
Sign but Cate f
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