HomeMy WebLinkAbout- Septic Pumping Slip - 1620 TURNPIKE STREET 4/3/2019 011
Commonweialth of Massachusetts
City/Town of .
Sy.4tem Pumpling-Record
FQrm 4
DEP has provided this form*for us&by local Boards 6f Health. Other forma may `used,but the
information-roust be substantially the tame as that provided here. Before using.this form,Check With your
to 'I Board of Health to determine the forth they use. The;System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facl-Oty ' f C i i o
1. System Location: Left/Right front of douse, Left/bight rear of house, Left/right side of house, left/
Right side of building, Left l i t front of buildifig, Left/Right rear of building, Under deck
wD � �`bt C_ S t
Address
City/Town state Zip Code
2. System Owner:
1 o
Name`
i
Address(if different from location)
City/Town ' State Zip Cade
"telephone Number
F•
Pumping r
1. Date of Pumping 25 at ` 2. Quantity Pumped: J
Gallons `
3. Type-of system: El Cesspool(s) [2 Septic Tank El Tight Tank t
El Other(describe):
4. Effluent Tee Filter present? El Yes 0 No If yes, was it cleaned? E3 Yes [3 No
S. Condition of System:
6: System Pumped By: t1
Neil.Batesort F5821
Name Vehicle License Number
Bateson Ehterprlses Inc
Company
7. Location where contents-were disposed:
G L SQ Lowell Waste Water
1
-- E
Sign �XHWZ����� Cate
t form4.dor,-08103 System Pumping Record Page 1 of 1