HomeMy WebLinkAboutSeptic Pumping Slip - 312 FOSTER STREET 4/11/2016 Commonwealth Massachusetts
RECEIVED
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Form 4
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. Information
1. System Location: Left/Right front of house, Left/Right rear of house t LrI sido of houses Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck _��
Address °
9
f/
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
Citylrown State, Zip
Cade
Telephone Number
B. i
Pumping ecor
1. Date of Pumping date 2. Quantity Pumped: Gallons
3. Type-of s stem:
y. ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes r3,gol
If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: / te
6; System Pumped By:
Neil.Meson F6821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati new re contents-were disposed:
�L S. Lowell Waste Water
sign a Haute Date
t5form4.doc•06/03 System Pumping Record• Page 1 of 1