HomeMy WebLinkAboutSeptic Pumping Slip - 193 FOSTER STREET 9/29/2015 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
1. System Location: Left/Right front of house, Left/Right rear of house,/right ddjof hous Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address � _C � ��` '�— �� �.•,_,�,/�, �'�������
City/Town State Zip Code
2. System Owner. V\V
Name l L( o
Address(i d.ifferen�ttffrpni lo�cat n)
. - State ^ Zip Code
Cityrrown '
j Telephone`Number
t?
B. Pumping Record �
1. Date of Pumping Date 2. Quantity Pumped: Gallons Y
3. Type-of system: ❑ Cesspool(s) 0-5eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes,was it cleaned? ❑ Yes ❑ No,
' 5. Condition of Systern: f�� 1✓�� � �`_��t/`-vT� . .�Lp �l_ ���'S�
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
S'. Lowell Waste Water
Sign a Haule Date
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