HomeMy WebLinkAboutSeptic Pumping Slip - 1659 OSGOOD STREET 5/2/2016 .
nw i of
I W of
r
System i Record
Form 4
so pr
tt4b�Cll��t/I I!�.)I f[f/"111(,1f�1/i:F�.
DEP has provided this fora for usezby local Boards of Health. tither forms maybe'usedpf�
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, I r aticn
1. System Locatio��'�--�Rigk�, ynt of hous , Left/Right rear of hous. ight side of house, Left/
Right side of buil7 inj;Left/Rig rant of building, Left/Right rear of uildmg, Under deck
Address µ
cityfrown State Zip Code
2. System Owner.
Name
( ) ,
Address if different from tocati��
City/Town ' State c Zi Cede
Telephone Number
Pumping 1 Rpcord
c
1. Date of Pumping ®ate 2. Quantity Pumped: Gallons
3. Type s stem:
yp y. ® Cesspool(s) Septic 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:
Neil.Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo lion-yvbere contents were disposed:
L S: Lowell Waste Water
Sign a ct Haule Date
t5form4.doc>06/03 System Pumping Record•Page 9 of 1