HomeMy WebLinkAboutMiscellaneous - 337 HILLSIDE ROAD 8/15/2015 i
ornrx>Ionwealth of Massachusetts
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City/Town of RECEIVED
item Pumping crd
Form 4 C��.j(:b � �a
J
ptiy F G'� Cw'C I Ai00VEJF
DEP has provided this form for use=by local Boards of Health. �-prm.l�cf to•used, but the
information must be substantially the same as that provided here. efore 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,f bui din Right/ Left/rear of
rear of bu in g, k fie, Left/
Right side of building, Left/Right front g, g g,
" Address
Cityrrown state Zip Code
2. System Owner:
Name'
Address(if different from location)
Citylrown Stat ATde
F
Telephone Number
i
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons _F
3. Type-of system: ❑ Cesspooi(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of stem:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo here contents were disposed:
7'GLS
. Lowell Waste Water
A Y Y V 4 `
Sign a Haute Date
0=4.doc•06/03 System Pumping Record•Page 1 of 1