HomeMy WebLinkAbout- Septic Pumping Slip - 570 BOSTON STREET 1/7/2019 Commonwealth of Massachusetts
City/Town of
System Pumpling Record I H 0
Form 4 IIEALTH DEFIAR,G W'-N
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 forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility InforMation
4�ii house
1. System Location: Left 0 i Vht Iron of house Left/Right rear of house, Left,/right side of house, Left I
ron To�ul
Right side of building, Left ig ron o uildifig, Left/Right rear of building, Under deck
Address
10 r 6-2
City/rown state Zip Code
2'. System Owner.
Name'
Address Of different from location)
Cityrrow" State- Zip Code
Telephone Number
.B. Pumping Record
Da ( � -C
1. Date of Pumping Date Quantity Pumped: Gallons
3. Type-of system: El Cesspool(s) agie�fic Tank E3 Tight Tank
[] Other(describe):
4. Effluent Tee Filter present? Ej Yes o If yes, was it cleaned? Yes No
5. Condition of System:
6. System Pumped By:
Neil.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
GX�SP Lowell Waste Water
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SigdWe ctHmu-1—L-V Data
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