HomeMy WebLinkAbout- Septic Pumping Slip - 426 SUMMER STREET 1/29/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Recor 0\Niq Or� t,,I\u()VER
Fonn 4 1 EAL'fH
DEP has provided this form for use=by local Boards of Health. Other forms May be'used,but the
informaflon•must be substantially the same as that provided here. Before using.this form,Check with your
local Board of Health to determine the forfh they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Inform' ation
1. System Location: Left/Right front of house, Left/gjt �t�rear of�hqu �Left/right side of house, Left,/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address (e:, So v�A oA er- &�- ..
cltyfrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town stater.
4 ode
Telephone Number
.13. Pumpling K-ecord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: E] Cesspool(s) 0--S�Spvc Tank Tight Tank
El Other(describe):
N 4. Effluent Tee Filter present.? Ej Yes [9- o"l-I If yes,was it cleaned? Yes ❑ No
5. Condition of System:
6. System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lor-a#"-ere content&were disposed:
Lowell Waste Water
Sign Date
I WnHilutu
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