HomeMy WebLinkAboutSeptic Pumping Slip - 353 BOXFORD STREET 8/5/2016 Commonwealth of Massachusefts
RECEIVED
x v
City/Town of
System Pumping.Record AUG 15 01
Form 4
DEP has provided this form for use=by focal Boards of Health. Other arms 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
1. System Location: Left/Right front of house, Left i f house;,Left/right side of house, Left 1
Right side of building, Left/Right front of building, Le building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name.
Address(if different from location)
Citylrown State iP Ccti e
Telephone Number
r
r ,
.B. Pumping !Record .,
1. Date of Pumping Date 2. Gtuan ity Pumped:
Gallons —'
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:
6: System Pumped By:
Nell.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locations where contents-were disposed:
C ^S:P Lowell Waste Water
Signituhe I Haule Date
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