HomeMy WebLinkAbout- Septic Pumping Slip - 190 BRIDGES LANE 6/24/2019 . RECE"AVED
,"�L\ Commonwealth of Massachusetts
..... ......
City/Townot
,l�y G r
L�
System PumpIng Record TOW�j 0 O"'Syr 1-11
,NDO E
IIII��'��' INIy
Form 4
DEP has provided this form, r use,;by l r 1 . r , but,
info,rmadon-
thetame as that provided here. Before us*ng.th'is forrn,check with yo r
locail Board of Healthine the for M" they use.TbeSystern Pumping Record
the local Board of Health r other approving
A. Factflity Information
I System Location: Left/Right front of house, Left R! ht 19
of house, Left. right slide of house Left,/
, . rearRight side:of building,
Address 10�
owe State Zip Cody
System2. r
1
Address(if diffetent from l
CityfTown statero
N Z� Ida
Telephone Number
.B. Pumping
1, Date of Pumping 2. Qu6nfity Pumped:
OtherDate Gallons
3. Type-of system,., E) cesspool(s) tic Tank 0, 'Tight Tank
UW�re7P'ie TanI
(describe!):
Filter4. Effluent Tee resea" , - cleaned?
5. ifl
System Pumped By.-
Nell. e$70 D5821
Name Vehicle Uicanse Number
Bates E rises, Inc
Company
were disposed,.
--,--C
6e, i
Sign Lowell Waste Water
t5ibrmikdoca,06/03 System Pumping Record