HomeMy WebLinkAboutMiscellaneous - 322 BOSTON STREET 8/19/2015 Commonwealth of Massachusetts RECEIVED
C4/Town of
S ' tem Pumping.R
Yecord AM',! 24 ?W 5
S
Form 4 TOMI OF NoRfl�MOOVEF�
HEM T H DEFAR�WE���
DEP has provided this form'for use;by local Boards of Health. Other forms may be used, b'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,, Left/Aighli rear of housp;Left/right side of house, Left/
Right side of building, Left Right front of building, Left flfti�jgrearo-f building, Under deck
7
Address
�_ t
Td-Y/Town state Zip Code
2. System Owner:
Name
Address(if differentfrom location)
CitylTown State
--,,Zip Code
Telephone Number
B. Pumping Rpcord
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type•of systerTf, ❑ Cesspool(s) Septic Tank F-1 Tight Tank
❑ Other(describe):
e
-Y-s-❑ Na
4. Effluent Tee Filter present.? 61e.� ❑ No If yes,was it cleaned? E3,
5. Condition of Sy te,.:
6.- System Pumped By:
Nell.Batesbg F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatiqn-vVhere contents-were disposed:
G,$L'S J D Lowell Waste Water
K
Sign e Higowle Date
06=4.doc•06/03 System.Pumping Record•Page 1 of 1