HomeMy WebLinkAboutMiscellaneous - 465 CHESTNUT STREET 8/17/2015 Commonwealth of Massachusetts REC EIVED
City/Town of
Y NJ(3 2 4 201
S * tem Pumping-Record
S
�tow�OF W�0 H 400VER
Form 4 HEALTH DEJ?P-R,l M E i 1,E r
DEP has provided this farm for usetby local Boards of Health. Other forms may be•used, but the
information-must be substantially the tame 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
If h
ear ho Left. right side of house, Left
1. System Location: Left/Right front of hous a Right<(ar 0
a re
Right side of building, Left Right front of b<�U !Irfig, Left I R!1gh rear of building, Under deck
Address
k\Q_A7-
City/rown Cke:15 State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityrrown state cd'Rre
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system-. ❑ Cesspool(s) ❑ Sept* Tank Tight Tank
9-"Other(describe):
4. Effluent Tee Filter present? ❑ Yep ❑ No if yes, was it cleaned? ❑ Yes r_1 No
5. Condition of System.: I
C)
6; System Pumped By:
Nell.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Inc
-Company
7. Lo ', At hr contents-were disposed:
Lowell Waste Water
7GL LL SQ
Q4_Y ra
Sign itu.Te f Haulet/ Date
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