HomeMy WebLinkAbout- Septic Pumping Slip - 155 CHRISTIAN WAY 5/7/2019 Jena+u a�Pick
�1 r
rd
4
Commonwealth of Massachusefts
City/Town
�q� r
u
of
9 �
v
x System
9
p
Form 4
DEP has provided this form for luseoby
local Boards l _ R
providedinformation-must besubst6rifially the tameas that using Ahis form,check with
loceil Board of Health to determine the tnin they use. The f
$ystern
must be submitted to
the local Board of Health or other approving
A. Facill"Ity InforMation
. y w: i house, Left. dght side of house, Left I
Right side of building, Left Right ir 6nt of buildifig, Left/Right rear cif buildin,g, Under de'ck
AddressJc
cityrr
own, Stattil zjip code,
. System
Frees Of diffefentfrom to -
City/Town
Telephone Number
.B. Pumping kecord
,u
1. Date of Pumping Date 2. QuMb Pumped: Gallons
3. Type-of system:
l I
Other(descrimbe):
I
4., Effluent T es Filter
r w If yes, Yes El No
. Condition.
6. System Pumped By.,,
Nell. b
Ina
Name Vehicle License Number
Bateson • Inc-
Company
G.,L S. Lowell Water
a
Sign l Date
t m Pumping Records Page i of I