HomeMy WebLinkAbout- Septic Pumping Slip - 7 SULLIVAN STREET 10/19/2018 RECEIVED
Commonwealth of Massachusefts
City/Town of
System Pumpling Record TGM0FWRMAN00V1iA
Form 4 kaL
DEP has provided this form for use-by local Boards of Health. Other forms may be'used, but the
information-must be substantially the tame 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. Facility InforMation
1. System LocaflonrO/high rant of house, eft/Right rear of.house, Left/right side of house, Left/
Right side of building, Left/RighRr:06�2toous%ild!fig, Left/Flight rear of building, Under deck
Address
C' 0 n —IT state Zip Code
2. System Owner
---i f
Name' i
Address(if different from location)
cityfTown stater Zip Code
Telephone Number
® Pumping Record
1. Date of Pumping Pumped:umped: Gallons
3. Type-of system: Ej Cesspool(s) 8Septic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present.? 01 Yes E] No If yes, was it cleaned? 0,1e-s�[O] No
5. Condition of System:
M
6. System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
company
7. Locati where contents-were disposed:
,7.- ,
Lowell Waste Water
Sign cfHhhuis Tat—e -
t5fbrm4.doc-06103 System Pumping Record•Page 9 of 1