HomeMy WebLinkAboutSeptic Pumping Slip - 1650 TURNPIKE STREET 7/19/2018 Commonwealth f Massachusefts RECEIVED
City/Town of
SyMem Pumpling,Record TOWN OF NOMI-1 ANDME-11
Form 4 HEALTH DEPAFUIAENT0
DEP has provided this forrri for use-by local Boards of Health. Other forms may be'used, but the
information-must be substantially tha same as that provided here. Before using.this form,check with your
lord Board of Health to determine the form they use. Tare System pumping Record must besubmitted to
the local Board of Health or other approving authority.
A. Facl"ty Infor Mation
I. System Conation: Left/Right front of House, Left/Right rear of house, Left/right side of house, Left
side of building, Left/Right front of building, Left/Right rear of building, Under deck
. address
Cityfrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityl7own ' Stag dip CCod ,
iG`1T
'telephone Number
ID
.B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. T e•of s stern: Tank ;
YP Y. Cesspool(s) � � p Tight Tank
El Other(describe):
4. Effluent Tee Filter present? Ej Yes if yes, was it cleaned? Yes El No,
5. Condition of System:
olua
6: System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Ehtarprles Inc
Company
7, Lot •-.
ere contents-were disposed:
L
Lowell Wash Water
C - CE
• f
WuqnHhule Date
l5form4.doc^06/03 System Pumping Record•page 1 of 9