HomeMy WebLinkAboutSeptic Pumping Slip - 150 BRADFORD STREET 10/15/2015 l
r
:4\ Commonwealth of Massachusetts
= City/Town of .
yitem 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: � /Ri front of h ._.
�� g � � ouse,)Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
( 6 _ - A v ..
Cikylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
i
citylrown State Zip Code
t "l
Telephone Number
3
.B. Pumping JRgcord . .
a
1. Date of Pumping LOS Date 2 Quantity Pumped: -- =
Gallons .-�
3. Type•of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
VCS
6: System Pumped By:
Neil.Meson - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
. a
Sign a Houle Date
t5form4.dof.-08103 System Pumping Record•Page 1 of 1