HomeMy WebLinkAboutSeptic Pumping Slip - 122 FOSTER STREET 4/11/2016 Commonwealth of Massachusetts
RECit�/Town of
EI
System Pumping- r °�tI
Form 4
DEP has provided this form for use=by local Boards of Health. Other forms may be'u ,L6Uf h&R,"1 M'
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the forr'rm they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Inform tion
1. System Location: Left/Right front of house, Left/Right rear of house, Left k igkmt si othouse Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
r
Citylrown State Zip Code
2. System Owner:
A
Name
Address(if different from location)
Citylrown State Zip , e
Telephone Number 4;
I;
B. PL!mping Record �
1. Date of Pumping Date -� 2. Quantity Pumped:
Gallons
3. TypeW system: ❑ Cesspool(s) c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yes No if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
s; system Dumped By:
Nell.Bates ri F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location-.whe contents were disposed:
G L S. Lowell Waste Water
�w
Sign t e 9f Haule Date
t5form4.doc>06/03 System Pumping Record•Page 1 of 1