HomeMy WebLinkAboutSeptic Pumping Slip - 520 BOSTON STREET 6/4/2016 Commonwe.alth a"
Cit�/Town of
System Pumping. r
.
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 tame 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
ofh:o1. System Location: Left/Right front of house Left Rig t rear , Left/right side of house, Left/
Right side of building, Left/Right front of b ' ' 'g, Left/ rear of building, Under deck
.4 ti
Address
N f!dx
Ctlylrown State Zip Code
2. System Owner.
O'belvis-
Name
Address(if different from location)
cityfrown State Zip Code ;
Telephone Number ice:
Pumping Record �
1. Date of Pumping Date 2• Quantity Pumped: Gallons —}---�
3. Type-of system: ❑ Cesspool(s) Septic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Ehterprises Inc-
Company ,
7. Lo tie wk contents were disposed:
G L S. re Lowell Waste Water
A E���7
610 Li t
Sign a f Ha-ule Date
t5fonM.doc-06103 System Pumping Record•Page 1 of 1