HomeMy WebLinkAboutSeptic Pumping Slip - 63 BRADFORD STREET 9/23/2015 Commonwealth of Massachusetts
_ City/°Town of .
YS tem Pumping card
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 Rlghtwrear of�i ms , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address .
Citylrown Statepde
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2. System Owner.
P 2 ,: 2015.
Name
Address(if different from location)
City/Town ' State .dip Code
Telephone Number
i
B. Pumping JRecord
..
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 0-14o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil.Beteson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location„-where contents were disposed:
Lowell Waste Water
Sign a 9t HaulerU Date
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