HomeMy WebLinkAboutSeptic Pumping Slip - 434 BOXFORD STREET 7/21/2016 Commonwealth Of � �
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Form 4
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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. Infer ti n
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTown ' State
Telephone Number
i
13. Pumping Kecord �.
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes D" 4o If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of Sys
6. System Pumped By:
Neil,Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loeati on, he contents-were disposed:
,.
. S. Lowell Waste Water
Sign a 9t HauleV Date
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