HomeMy WebLinkAboutSeptic Pumping Slip - 1551 OSGOOD STREET 6/18/2016 Commonwe.alth of Massachusefts RECEIVED
v C it�/Towno
_ . t , Pumping.
Forma 4 1�: vii:�.�. ��.�c r pj )(:),tE R
DEP has provided this form'for use=by local Boards of Health. tither 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.
Facility. Information
1. System Location: Left/Right front of houses Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Rig front of buildin�", Left/Right rear of building, Under deck
Address - w,
" G C
CWTown State - Zip Code
2. System Owner.
M
Name
Address(if different from location)
City/Town State- e"" _Zip Code
t
Telephone Number
Pumping Record
1. Date of Pumping `- 2. Quanta Pumped: —�
Cate Gallons .
3. Type of system. ❑ cesspool(s) 'Septic Tank ❑ Tight Tank
❑ Other(describe): t
4. Effluent Tee Filter present? El Yep ❑14o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatienhere contents-were disposed:
G L S Lowell Waste Water /
sign a f Flaule Date
t5form4.doc•06/03 System Pumping Record Page 1 of 1