HomeMy WebLinkAbout- Septic Pumping Slip - 25 MILL ROAD 6/24/2019 ofp' Massachusetts
City/Town ot
System Pumping Record TOM
C%bmmonwealth
,
,���
°Form 4
DEP hais provided this form for useoby 1=1 Boards of-Hiealffi. Other
informadon-must
l ° Boardlth to determine the for h they use.,ThaSystem Pumpingrsubmitted to
Healththelocal Board of r other approving authority.,
Right side of A. Facility InforMation
1. System Location: Left/Right front of house, e Ight(jj:aj�o Left. right side of house, Left I
building, r
r I r k
Address
IVO(�7A-k, A-\�
c state Zip Code 2. �ys :' Owner:
Address different from location)
cityffawn State~ Cod
Telephone u r
B. Pump"Ing Record
1. Date of Irk t Qu6nfity Purnped:
i
Gallons
3. Type-of systeml: Ej Gesspool(s) 0-1epfic Tank, Tight'Tank
0 r ray
4. Effluent it r r Yes MI rIO if yes,was it cleaned? Yes [] No
5. Condition of System
6. System Pump
Nell,Ba 5821
Name Vehiclens Number
Bateson gi��erlses Ina
Company
where7. Location rdisposed:
Lowell Waste Water
.. Coo
Sign a Hhul Date
J,
Obrim4.doca 08103 System Pumping Record Page I of I