HomeMy WebLinkAboutSeptic Pumping Slip - 96 FARNUM STREET 6/28/2016 Commonwe'alth of Massachuseffs
i wn of . R :,� ED
y tem Pumpin§.Record
Form 4 J lJ L. L. .k X(J 1R')
DBP has provided this form for usez by local Boards of Health. Other forms may sadi,bpti-thy m
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
1 � h i ause, Left/right side of house, Left
Right side of bu IdingLeft 9Rigft front of building, ft/Ri ht rear
of building, Under deck
Address
City/Town S ate Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityrrown State i (�de
Telephone Number
• r ,
. Pumping ✓Rpcord ,
1. Date of Pumping pate 2. Qu�'3,rtf"Pumped: Gallons
3. Type-of system".yp y ❑ Cesspool(s) eptic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes [ ' Jo If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of st m:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Lo9tlof�i"ere contents were disposed:
Lowell Waste Water
Wi&A �...
SignAtu I fe I Haule Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
