HomeMy WebLinkAbout- Septic Pumping Slip - 15 BRADFORD STREET 10/2/2018 Commonwealth u Citk/To
WC0 2 2 018
Sy.4tem Pumping.Record
Form 4
DEP has provided this form`for use-by local Boards 'of Health. Other forms may be'used,but the
lnformadon�must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use. The;System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. c[ Info
1. System Location: left/Plight front of house, e /Rig ar of hou Left/right side of house, Left f
Right side of building, Left/Right front of bur tt al, Left rear of building, Under deck
Address A-L-A
Cityfrown State Zip code
2. System Owner: „ Y
Name'
Address(if different from location)
City/Town State, Zip Code ;
Telephone Number ' ?
r
i
e
q Ar
1. Gate of Pumping pate L 2. Quantity Pumped: Gallons
3. Type-of system: [] Cesspool(s) eptic Tank [j Tight Tank
(� Other(describe):
4. Effluent Tee Filter present? El Yeas o If yes, was it cleaned? E Yes No,
6. Condition of System:
V)luzej V\1_1r1(AAA_'"C_
v f
6. System Pumped By: i
Nell.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc•
Company
7. Location..where contents-were disposed:
%LS.AV Lowell Waste Water
Sign e cqfHim WU
pate
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