HomeMy WebLinkAboutSeptic Pumping Slip - 706 FOSTER STREET 7/18/2016 Commonwealth f Massachusetts J,k , rr rrory1lpoully
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_ City/Town of .
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Form 4
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 Information
I. System Location; Left/dig t front,of ho , 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
_ •
City/Town State Zip Code
2. System Owner,
V j k
Name'
Address(if different from location)
City/Town " State r Zip co
Telephone Number
. Pumping Record
1. Date of Pumping Date l 2. Qua Gallons
ntity Pumped:
. �„,,-•- t—�
3. Type of system: ® Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System; s
6. System Pumped By:
Neil.Bates-on ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. LOCAJJlo . re contents-were disposed:
. 4
G1 S'. Lowell Waste Water
a
Sign a Haule Date
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