HomeMy WebLinkAbout- Septic Pumping Slip - 500 REA STREET 1/8/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
DEP has provided this form for us&by local Boards of'Health.Other forms maybe'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 forrin they use.The System Pumping Record must be submitted t®
the local Board of Health or other approving authority.
A. Facility information
1. System Location: L6ftQfitjf=ront off , Left/Right rear of.housig, Left./right side of house, Left,/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Ufii-y—trowln state Zip Code
2. System Owner:
Name*
Address(if different from location)
City/Town staW.-� —Zip code
7;361-
Telephone Number
13. Pumping Kecord
V -39
1. Date of PumpingCate 2. Quantity Pumped: Gallons
3. Type-of system: E] Cesspool(s) ptic N'Tank Tight Tank
El Other(describe):
4. Effluent Tee Filter present.? El Yes [9-14-0�1 f yes, was it cleaned? 0- Yes El No
5. Condition of n m:
� I
6. System Pumped By:
Neil.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Lo re contente were disposed:
.5
G, & Lowell Wastee Water
Sign a Haul Date
t5fbrm4.doo-06/03 System Pumping Record d Page 1 of 1