HomeMy WebLinkAboutSeptic Pumping Slip - 193 BOXFORD STREET 6/13/2016 Comm
On wealth
Cit�/Town of
S item YS
Pumping-Record WIJ /Ijlri
Form 4 'TO Ml OF p A""1F€I 11 MJ[)0\11ER
DEP has provided this form for use�by local Boards of Health. Other fo6 4 'y t , 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/Algght rear of hous a Left/right side of house, Left/
Right side of building, Left/Right front of building, Left TRiglif rear®f building, Under deck
Address •
3
CRy/rown State Zip Code
2. System Owner: Y
.
Name'
Address(if different from location)
Citylrown State .,.. i c Z! Code
r
• r r r'•
Telephone Number
B. Pumping pcor �..
Mons
1. Date of Pumping 2. Quantity Pumped: )
Date Gallons
.....
3. Type•of system: ❑ Cesspool(s) ( 'Sep tic Tank [I Tight Tank
❑ Other(describe):
p E] Yes mNa .... If yes, was it cleaned? E] Yes E] No,
4. Effluent Tee Filter resent?
5. Condition of System: mmW
6: System Pumped By:
Neil.Mason F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lopatio"fhere contents were disposed:
Lowell Waste Water
UA. Bz6z-z
Sign a qj Haule Date
t5form4.doc•06/03 System Pumping Record.Page 1 of 1