HomeMy WebLinkAboutSeptic Pumping Slip - 102 BRADFORD STREET 12/17/2015 Commonwealth of Massachusetts
City/Town of �"
Syitem Pumping,Record
Form 4 ':��r�nr
DEP has provided this form for use=b local Boards of Health. Other forrne"'6 �`
p y �n� 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 Af iigh
y g g � t side of house; Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
G
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityirown State � -
cs
t Telephone Number �+
B. Pumping Record
1. Date of Pumping pate �epfiuc ntity Pumped: Gallons y�
3. Type-of system: ❑ Cesspool(s) ® Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
h
• �_.- .�.��.��per_._.
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locqtion re contents were disposed:
G L S Lowell Waste Water
\-f nOA
Sign a 9t Hiauleqj Date
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