HomeMy WebLinkAbout- Septic Pumping Slip - 90 BOSTON STREET 1/7/2019 Commonwealth of Massachusetts
Clty/Town of
System Pumping Record
Form 4 i j;,
DEP has provided this form for use>by local Boards of,Health. Other forms maybe*used,but the
information,must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the forrh they use.The Systern Pumping Record must be submitted to
the local Board of Health or other approving authority.
A0 Facility InforMation
1. System Location: Left. /Right front of hour Al lghtF;-a'jqftouSj�Left-/right side of house, Left I
1..[P
Right side of building, Left/Right fr6nt of Ling, Left/Right rear of building, Under deck
Address CD
RD fz;�z
city/rown state Zip Code
2, System Owner. �`����,
Name'
Address(if different from location)
Cityfrown Stater Zip Code
Telephone Number
.13. Pumping Ptecord
1. Date of Pumping ate 2. Quantity Pumped: Gallons
3, Type-of system' E] Cesspool(s) 0-Ve—pt—to-T—ank ❑ Tight Tank
El Other(describe):
4. Effluent Tee Filter present? El Yes 3-14;� If yes, was it cleaned? Yes ❑ No
S. Condition of Syster&�,
lac t� .��s?-.-- `� �..M---�� �..;�---�
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L e content%were disposed:
G.L Lowell Waste Water
Sign e H&VIKU Date
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