HomeMy WebLinkAboutSeptic Pumping Slip - 207 BOXFORD STREET 8/11/2016 Commonwealth of Massachusetts
City/Town of AUG
'
S S N�Pum in -Record OF WX��HAKE¢:�
o
Form 4
S
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. lnforMation
1. System Location: Loft/Right front of house, Left/ lght;iear of hauSe, Left/right side of house, Left/
Right side of building, Left/Right front of building, a it rear cif building, Under deck
Address
m
City/Town state Zip Code
2, System Owner.
Name`
Address(if different from location)
city/Town ` State, Zi
Telephone Number
i
.B. Pumping Record
1. Date of Pumping Date 2. Quantity a Pumped; Gallons
I
3. Type-of system: F`) Cesspool(s) epric Tank 0 Tight Tank
❑ Other(describe).
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: ,( A
•
6: System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Loca'o�'er contents.were disposed:
G L Lowell Waste Water
Sign a Haule Date
t5f6rm4.doc•06/03 System Pumping Record•Page 1 of 1