HomeMy WebLinkAboutSeptic Pumping Slip - 119 LIBERTY STREET 11/10/2015 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 Ri ht Left/right side of house, Left Right side of building, Left/Right front of building, Left building, Under deck
Address
J ((
City/Town State Zip Code
2. System Owner. 4
Name
Address(if different from location)
CiVrown ' State Zi Code ;
Telephone Number
.B. Pumping JRmcord �.
1. Date of Pumping Date 2. Quantity Pumped: Gallons i
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ Nc If yes,was it cleaned? Na
5. Condition of System:
6.. System Pumped By:
Neil.Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati
contents were disposed:
7L_ �D Lowell Waste Water
Sign a I Haule Date
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