HomeMy WebLinkAboutSeptic Pumping Slip - 105 SULLIVAN STREET 12/17/2015 Ir .
Ot�nrnnwealth of Massachusetts
_ City/Town ®f
Sy item Pumping-Record
Form 4
DEP has provided this form for usezby 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, Left Ari— side of house Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address . /',r� , 1 �� 1,)C�%`,: ,,,r�,,. �� i4VC w.ae. �1� (i
Cityfrown f (� State Zip Code
2. System Owner:
Name'
Address(if different from location)
Citwown ' Stag c t 4 Zip Code ;
F
Telephone Number +`
B. Pumping JRpcord
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No if yes, was it cleaned? - Yes ❑ No,
' 5. Condition of System•: -
• ctuc,
6. System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
S: Lowell Waste Water
SiqnAtufe 9f Houle Date
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