HomeMy WebLinkAbout- Septic Pumping Slip - 450 BOSTON STREET 5/15/2019 y�
wm
u
15
Commonwealth of Massachusefts
a
City/Town
of
System
7sf M,
lµ
r Pumping
a
Form 4
DEP
has prow6ded this form for p l f-Health. Other fr may,be,*used, the
information,l f .sf lly the tame,as that provided here. Befdre us r, .this fog,C'heck with your
10061 Board of Health t6 determine the f they use. The�Systern Pumping Record must be submi'tted to
this local Board of Health r other -proving authority.
A. Facility Inform' afloon
System L bony h, front f house, 19, rear f ous -0:�911UJQ8 f s�a "
Right si'de ofibuilding, Lefthf fr � f � i - Right gear cif builder er deck ru
�
Address
o
cftyf rown state Zip Cody
2. System Owner.
Nainao
Address(if different from location),
Citynown
Telephone Number
.B. Pumping Kocord
be
1. Date of PumpingData . uty Pumped: Gallons
OtherI Type-of system" Cesspool(s) eptic Tank [I T' ht Tank
(describe):
4. Effluent Tee Fifter r Y if Yes,,was ift cleaned? Yes No
5. Condfion of System: C c�e
. System Pumped Bly.
NeallM Bateson F5821
Name Vehicle License Number
Bateson Ehte!pr Inc-
Company
7. bon content&were disposed:
Lowell Waste Water,
Sign e I
Pumpingr a page I of I