HomeMy WebLinkAbout- Septic Pumping Slip - 140 GRAY STREET 10/31/2018 Commonwealth of Massachusetts I'V, Q, �IVEA,.,D
City/Town of
System Pumpling Record
"FOWN OF MO",I H MOAVER.
Form 4 EAL M[)F�-NROMEN'F
DEP has provided this form for use-by local Boards ofHealth. Other forms maybeused,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 Locatio : L CfiJ" ig Left/Right rear of house, Left./right side of house, Left I
Right side of budig�, Lelft' 3fr0:ofn:'too:Ufb;u'ildIfig, Left/Right rear of building, Under deck
Mo
Address
Cityfrown state Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityrrown $false,)
Telephone Number
13. Pumping Record
1. Date of Pumping Data 2. Qua'no' Pumped: Gallons
ti 3. Type-of system: El Cesspool(s) �epflcaTank Tight Tank
Ej Other(describe):
4. Effluent Tee Filter present? E] Yes o
lf yes, was it cleaned? Yes No
5. Condition of System:
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio ere contents-were disposed:
Lowell Waste Water
_sign Aqi_4_ Haul Crate
Date
15fbrrn4.doo-08/03 System Pumping Record dPage 9 of 1
