HomeMy WebLinkAboutSeptic Pumping Slip - 506 BOSTON STREET 6/30/2016 Commonwealth
YSs
Form 4 �
DEP has provided this forms for use=by local Boards of Health. Other form's may be usek".U�t�ih�`e'
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, Inf®r alficn
1. System Location: Loft/Right front of house + ig dear of aus�,�Left/right side of house, Left/
Right side of building, Left/Right front of bul ding, Left I Right rear of building, Under deck
Address
µ,
C �
ZiCitylrown State p
2. System Owner:
Name
Address(if different from location)
Cityfrown ` State
Ziade
s 'telephone Number
i
1`f
Pgmpin eccr
1. Date of Pumping ®ate 2. Quanti Pumped: Gallons
3. Type,of.system: ❑ Cesspool(s) Septic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® es ® No If yes, was it cleaned? s" No,
' 5. Condition of 5yst Y
6.. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. L7LZL,1 n1w contents-were disposed:
: Lowell Waste Water
SignAtu a cf Haule Date
t5form4.doc•06/43 System Pumping Record•Page 1 of 1