HomeMy WebLinkAboutSeptic Pumping Slip - 443 BOSTON STREET 7/18/2016 Commonwe'alth of Massachuseffs
Cit�/Town of
ump
x
i r r
E, o f j
YS
.�` Form 4 a
DEP has provided this form for uset by local Boards of Health. Other forms may be use ,
Information-must be substantially the tame as that provided here. Before using.this form, check with your
local Board of Health to determine the forth 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/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 (� w �
Citylrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State Zip Code ;
t
Telephone Number
B. Pumping cord
..u� b
1. Date of Pumping sate 2. Qu cttity Pumped:
Gallons —"
3. Type of system. ® Cesspool(s) optic Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes No,
5. Condition of System:
6. System Pumped By:
Neil,Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. L ct"ionhere contents were disposed:
G L S Lowell Waste Water
OA
Sign a Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1