HomeMy WebLinkAboutSeptic Pumping Slip - 171 ABBOTT STREET 12/2/2015 Commonwealth of Massachusetts
City/Town of .
YS'te m Pumping-Record
1
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be'used, but the 1
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the forme they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
g 9 lg e W1 W
1. System Location- Left/Right front of h of building,/ Left/Right rear of building,/�rl U de oeckous�Left/
Right side of building, Left/Right front g
Address
City/Town State P Zip Code
2. System Owner
r
r
Name
Address(if different from location)
Citylrown ' State "Zip t.' d e. l./e ;
Telephone Number
1 ,
B. Pumping Ripcord •.
1. Date of Pumping Date 2. Quantity Pumped: Gallons Y
3. Type-of system: ❑ Cesspool(s) ❑°~"septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑Y0 If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: '"
6.. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises
Inc-
Company
7. Location- ere ontents were disposed:
.L S. } Lowell Waste Water
7 - A
VrO
Sign a ct Haule Date
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