HomeMy WebLinkAboutSeptic Pumping Slip - 112 FOSTER STREET 4/11/2016 Commonwealth of tt
. M
City/Town of
a System. Record
Form 4
DEP has provided this fora 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 C�- rear®f hou ,Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address y
CitylTown State „ '
2. System Owner:
W„
Name' . 0WN U°l U,--,1THrtND OV[@'"
1110 LDI i:)VVCtR"f1V Iifl
Address(if different from location)
Cityrrown Stat Zip Co
Telephone Number
B. 1
Pumping Record
1. Date of Pumping sate 2. Quantity Pumped:
Gallons
. ❑ Cesspool(s)3. T yp e of system' e tc Tank
❑ Tight Tank
❑ Other(describe): .
4. Effluent Tee Filter present? ❑ Yes ONo 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. Locatio x'ghere contents were disposed:
rL S, ,,, Lowell Waste Water
Sign t e Haule Date
t6form4.doce 06103 System Pumping Record.Page 1 of 1