HomeMy WebLinkAbout- Septic Pumping Slip - 260 BRADFORD STREET 12/16/2020 Commonwealth of Massachusetts RECEIVED
I WCity/Town of
System Pumping Record DEC 16 2020
_ —,Form 4 o-NURIH MDOVTER
DEf has provided this form for use-by local Boards of Health. Other forms maybe used,but the
information must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left/Right front of house / gh rear of hoyW Left/right side of house, Left
Right side of building, Left/Right front of b ' , Left/ g rear of building, Under deck
Address �� ,q AE_ �
Cityfrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Telephone Number
B. Pumping K-ecord
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. =SS.
contents-were disposed:
L. Lowell Waste Water
SignAWe qt Hauler(/ Data
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