HomeMy WebLinkAbout- Septic Pumping Slip - 54 VEST WAY 10/2/2018 Commonwealth of Massachusefts
m
Clt" /Town of
System Pumpfn§-Record
Form 4
DEP has provided this f r'm for use-by local Boards 6f Health. Other forms r ay'b used, but the
information,mu b substantially the m here.rm r usi .thi form,check ith your
local Board of Health to determine the forfn they use. The, Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facill.ty, M
y on: /Right front f tics L
1. erg Location: ght r.. -LisL right side of house, Lift
Edo ht side of building, Left Right fret of building, Left f r building, Under deck
Addressp
` rw
cd.Iffrown state dip Code
2m System Owner ? �«
�9rsro�'
Address(f different from 90 Gn)
Tole ahene 6 urrab r e`
7
B. Pumping Rpcord
µ
1 a date of Pumping uantity Pumped:
e Gallons ,.
. Type-of sy erg: El Cesspool(s) ti Tanis Tight Tank
Other(describe):
4. Effluent Tee Falter present? o if yes, was it cleaned? El y No,
' . Condition of stem:
System Pumped By.
Nell.Batesbn ` P58 1
Nerve Vehi e Ulcanse Number
�n laC�t rises ir��`
Company
. Locati. re ntents-were disposed:
rC� Lowell Waste Water
sign H,U data
t 4.do 06103 System Pumping Record ago 19f 1