HomeMy WebLinkAboutSeptic Pumping Slip - 307 REA STREET 12/17/2015 'S" Commonwealth of Massachusetts
City/Town of C �(V E D
A
System Pumping.Record
Form 4 R)M4pprpp�pee,�:ryry tT I M MOVEF,�
M&ff
DEP has provided this farm for use=by local Boards of Health. Other forms may be'used, b'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: LefI;tkr_g`6tj[o
Cfront of house t rear of house, Left/right side of house, Left
��, Left//Right
Right side of building, Left Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town Stat Zip de
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quainti�t_Pumped:
Gallons
3. Type•of system: ❑ Cesspool(s) O-S-ep-fic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? r-1 Yes ❑ No,
' S. Condition of System
6.- System Pumped By.,
Nell.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loca 7 n- 7 c
�ere ontents-were disposed:
10
GLS*.D Lowell Waste Water
1-44,SJA
Sign itu I Te 9t Haulejj Date
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