HomeMy WebLinkAboutSeptic Pumping Slip - 100 FOSTER STREET 5/2/2016 Commonwealth
C41Town of . y
YS
t Pumping, or
r` Form 4 � �
DiEP has provided this form for use-by local Boards of Health. tether formtlm 6?,,4pe, vbbi the
information must be substantially the same as that provided here. Before�rs�ng. hls farm, 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
I. System Location: Left/Right front of Mouse, Left/Right rear of hour. �91 � 6s
Right side of building, Left/Right front of building, Left/Right rear of building,�g side of house; eft
y g g
�" Under eck........°w_ _
Address
CitylTown State Zip Code
2. System owner.
Name'
Address(if different from location)
ci /Town '
tY Stated�r°":� .� ip Code ,
' a
Telephone Number
13. Pumping Rpcord L6
1, Date of Pumping Date 2. Quantity Pumped: Gallons N
3. Type-of system: ❑ Cesspool(s) 0-peptic Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes o if yes, was it cleaned? ® Yes ❑ No,
5. Condition of st m:
6: System Pumped By:
Neil,Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
L�ry
7. Loca -w Whre contents were disposed:
te �
Lowell Waste Water
eignituhe I Haule Date '
t5form4.doc•06/03 System Pumping Record•Page 1 of 1