HomeMy WebLinkAbout- Septic Pumping Slip - 103 BRADFORD STREET 6/24/2019 1
1
1
f � RECEIVED
4L\ Commonwealth
r
City/Town of
r
sefts
..System
Record'
"T V9 MOM ,�J,1 l i HA N NI'` �I��uY
1v, i� �,�iU, Diu w�rr�u
Form 4
IIw f� (�f!Nµ i
V/l�U'/IJJ��tiVti� // (Ihw � '/d&�W W IIW I1h(((2'
4��NM 9S r,
DEP has
provided this form for u 0by� local Boards of Health. r form,may,beused,b9t the
information-must be subst6ntially thes that, providedhereusing.this form,,check with!your
local Board of Health to determine the four they use. The� Record must be submitted
the.local Board of'Health or otherapproving authority.
A., Facill"I
. System Location: Left/Right front of house, Left I � ri i 4
Right ibuilding, i d , Left Right rear " it i r "
ck
Address
w
J\j
OftylTbwn State Zip Code
,, System Owner.
W�
Name'
Y
+ a-
Address from l ion)
Cityfrown stater olde
Telephone Number
"
B. Pumping Record
.
I 00N
eolo-
. PumpingDate of � 'urns
ate all
3, Typie-of system,: El l Tank Tightk
Other�D (describe):
4. Effluent Tee i
Ff"Iter r Yes 04, Iit cleaned? El Yes El No
5. Conidifion of System:
4Z�7t
6. Systerh Pumped
Nell. ate �on F582
Name Vehicle Ucense Number
compare
re,contentswere disposed.
Lowell'Waste Water
Si I Date
Pumping Record Page 1 of I