HomeMy WebLinkAboutSeptic Pumping Slip - 174 BRADFORD STREET 8/26/2015 Commonwealth of Massachusetts
�' J
City/Town of
System Pumping.Record
Form 4
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 tame as that provided here. Before using.this form., check with your
local Board of Health to determine the forrh they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. house h
System Location: Left/Right front of hous _aPRIg rear'of h Left right side of house, Left
Left/��. o
Right side of building, Left Right front of b 10 �0
uildifig, Left/ ight rear dif building, Under deck
Address
Cft_vf rown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityrrown State 1p Code
oe ko
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
❑ Cesspool(s)
3. Type of system: 0--Septic Tank M Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present.? ❑ Yep 9-N-o If yes, was it cleaned? F-1 Yes r_1 No,
5. Condition of System:
6., System Pumped By:
Nell.Batesbn - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio _7ere contents were disposed:
"o
Lowell Waste Water
q 'MOA
_6715nAttle 9t Haulejj Date
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