HomeMy WebLinkAbout- Septic Pumping Slip - 487 WINTER STREET 6/4/2019 EL( IMED
Commonwealth
..QN
lop
i City/Town � f �ill
;
m
(�laN iNd
w M . w����Ill:�u��„w����� b`'��,��,III�����41������
W
System,
o T
Form 4
DEP
I
,i � l A Imaybe but
" , d ill d f ion � _,check with your
.
itte to
cil Board of Heaith,6 determine the for M" ,they The$yste�m Pumping Record,must be Subm d
the local Board of Health or other approving authority.
A,, Facifity Inform' aflon
1
System
Location-� Rig of " * house, . 'right sidehouse, Left I
Right side bull L Rf,6Address
LO_.--I, Q)\'%-k , , 4 i
cftyfrown " Code 1
Systemw
1
ao
t
Address Of different from location)
C _2�ipCZde
I oweStater
Te!leph,one Number
1. Date of Pumpling Date B. Pumping Record
system: ty Pumped: Gallons
Cesspool(s) epfic Tank E] Tig h,t Tank
Other(describe);
., Effluent T *1 nth Ej Yes I , leaned?
. Condition
i
System y
Nell.Batesbn
r
Nary Vehicle Lfse
line-
company
7. Location where contenter were disposed.
, Lowellte Water
Sign a qf Hbul Date
t5form,4.dacp 08/03, System Pumping Record Page