HomeMy WebLinkAboutSeptic Pumping Slip - 15 BRADFORD STREET 8/22/2015 Commonwealth of Massachusetts ........It
City/Town of
Record
fl System Pumping-
Form 4
k-;
DEP has provided this form for usezby local Boards of Health. Other forms may be'used, b'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
1. System Location: Left/Right front of housN lgh@e�ar'of hou Left right side of house, Left
Right side of building, Left Right front of bu�l�?ihga., Left/'Right rear of building, Under deck
Address
Cityrrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityrrown State _ZIP Ida
Telephone Number
.B. Pumping Rpcord
1. Date of Pumping 2. Quantity Pumped:
Date an Gallons
3. Type-of systeryi., ❑ ' Cesspool(s) 046-p-ric Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep 0--`N�o If Yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
AA-
6.- System Pumped By:
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
^L S1 Lowell Waste Water
1 WOO
Sign cf Hauler(L/ Date
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