HomeMy WebLinkAboutSeptic Pumping Slip - 328 SUMMER STREET 8/28/2015 Commonwealth of Massachusetts
W
City/Town of
System Pumping.Record
. .w
Form 4
5.
DEP has provided this form for use=by local Boards of Health. Other forms may be used,
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. eft`�W g runt of hous Left/Right rear of house, Left/right side of house, Left/
Right side of bull m /Rig ron o building, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner:
Name'
Address(if different from location)
Citylrown ' state/1 Zip Code
Telephone Number r'
B. Pumping JRecord
1. Date of Pumping Date 2. Qu6nW Pumped: Gallons r
3. Type-of system. ❑ Cesspool(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:
^ \ Vfi
6: System Pumped By:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7.jSigne wVirtr contents were disposed:
. Lowell Waste Water
Haule � � Date
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