HomeMy WebLinkAboutSeptic Pumping Slip - 300 FOSTER STREET 5/17/2016 : Commonwealth of Massachusetts
City/Town of .
System Pumping-Record
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
I. System Location(eCRA/Rlghtront of hour Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/.rown State Zip Code
2'. System Owner. l � �n
�1/l Cam.,V \
Name
Address(if different from location)
Cityrrown State Zip Code
Telephone Number
f`
.B. Plumping JRpcord
1. Date of Pumping �J �' J 2. Gantity Pumped:
Date Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Yes ❑ No If es, was it cleaned? Yes N
Y ❑ a
5. Condition of System:
Doc'Acd
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location-where contents-were disposed:
GLS'.D Lowell Waste Water
Sign a f Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
