HomeMy WebLinkAboutMiscellaneous - 34 LIBERTY STREET 8/19/2015 i
Commonwealth of Massachusetts RECEIVED
City/Town of . �ja) ' `1 701
t' T PU1� 1rRecord/S :()\Wl C
Form 4 I10M.JH wl*RPA,,�J
DEP has provided this form for use-by local Boards of Health. Other forms may be'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 1 ht front of tiouse�eLeft/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address 114
City/town / J State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town StaL Code
Telephone Number �4
i
B. Pumping Record .
1. Date of Pumping Date 2. Quantity Pumped: Gallons a
3. Type-of system: ❑ Cesspool(s) 0~-S-eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 0'-N-
No If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of Syste
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
_Bateson Enterprises Inc-
Company
7. isigne her contents were disposed:
Lowell Waste Water
f
Haule Date
t5form4.dov 06/03 System Pumping Record•Page 1 of 1