HomeMy WebLinkAbout- Septic Pumping Slip - 75 GRANVILLE LANE 10/31/2018 Commonwealth of Massachusetts F,tr-CEIVIED
City/Town of
tem Pumpling Record
S ' t4 OF�4( moovm
Form 4 itE I ALIH I)EVIARIMENT
j0W'
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
lo 'I Board of Health to determine the form they use.The Pumping Record must be submitted ca tc)
the local Board of Health or other approving authority.
A. Facility Infor M' aflon
I. System Location: Lek/Right front of house, Left I Right rear of house,(!*-Aigh g(djofho*us Left
k
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address e-r- LV\_
cityrrown State Dip Code
2. System Owner:
Name
Address Of different from location)
Cityfrown Stater 11 p Code
Telephone Number
.B. Pumpling Record
9. Date of Pumping Date 2. Q1 'nuty Pumped: Gallons
3. Type-of system: E] Cesspool(s) 0--6eprla Tank Tight Tank
[I Other(describe):
4. Effluent Tee Filter present? [] Yes 0----N�o If yes, was it cleaned? El- Yes El No
5. Condition of System:
6. System Pumped By.,
Nell.Batesbg F6821
Name Vehicle Ucense Number
Bateson Enterprises Inc,
Company
7. Loca I tio"re contents were disposed:
Lowell Waste Water
85
Sign e Houl Date
15fbryn4.dc)c-08/03 System Pumping Record¢Page 9 of 1