HomeMy WebLinkAbout- Septic Pumping Slip - 1620 TURNPIKE STREET 3/18/2019 Commonwealth of Massachusetts
City/Town of
System Pumping Record TOVO4 D
Form 4 u,IEALTH I)L,,J"'/,�1`,,TMST[
DEP has provided this form for use-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 forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility In for Mation
1. System Location: Leh/,ki�g�ht1fpguj1�Q2fbPweLeft/Right rear of house, Left./right side of house, Left/
Right side of building, LeX r tq Left/Right rear(if building, Under deck
Address
City/Town State Zip Code
2. System Owner
Name'
Address Of dikWariff—om location)
CltyfTown State Zip Code
'T7 q-
Wlephone Number
.13. Pumping Record
1. Date of Pumping Date 2. %Q,uu�rajnxl U Pumped:
Gallons
3. Type-of tam: El cesspools) Septic Tank Tight Tank
Sys' I I
;Other(describe):
4. Effluent Tee Filter present.? El Yes DINO-l" If yes, was it cleaned? Yes ❑ No
5. Condition..of Syste
................ . .m:�
6. System Pumped By:
Nell.Bates on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
G,L 848. Lowell Waste Water
Waste
Water
Sign a Date
l:6fbrm4.doc-08/03 System Pumping Record Page 1 of 1