HomeMy WebLinkAboutSeptic Pumping Slip - 90 BOSTON STREET 4/11/2016 Commonwealth of Massachusetts RECEIVED
u it /Town of
System Pumping Record,
Form 4 [OWG4 0F Luc)F"ri iMOMvER
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DEP has provided this form 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. Infr tin
1. System Location: Left/Right front of house Lie Aightcre—'j;f usss Left/right side of house, Left/
Right side of building, Left/Right front of building, Left I Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Bzz,,,�
t
Name
Address(if different from location)
City/Town S#ate P Zip Code
F
Telephone Number �n
B. j
Pumping Record
Ut
1. Date of Pumping 2. Quantity Pumped: —
Date Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:6. System Pumped By:
Nell Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7; Location where contents were disposed:
L5. M1 Lowell Waste Water
Sign t e Hauls Date
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