HomeMy WebLinkAboutSeptic Pumping Slip - 7 INGALLS STREET 9/14/2015 : Commonwealth of Massachusetts
_ 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, 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: Left/Right front of house, Left/Right rear of house eft;Ligh !id�oqf hour , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Un
Address
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityfrown Stated R Z p de
Telephone Number
I
B. Pumping ,record �..
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L3"No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sy to
6: System Pumped By:
Neil.Bates ri F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatign_w ere contents were disposed:
zC6LS_b Lowell Waste Water
SignAtufe cf Haule Date
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