HomeMy WebLinkAboutSeptic Pumping Slip - 838 OSGOOD STREET 9/14/2016 : Commonwealth of Massachusetts
g C4/Town of
System Pumping-Record WF
r 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, tnformatlon
1. System Location: Left/Right front of house, Left/Right rear of houseLQPrigh si a of house, Left I
Right side of building, Left/Right front of building, Left/Right rear of building, Under❑'c❑
Address _
Citylrown w„ State Zip Code
2. System Owner I--
Name'
Address(if different from location)
Cityfrawn State, , e L _ p Gods
ti Telephone Number d —
i
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
r
3. Type-of system: ❑ Cesspool(s) ' ❑~Septic Tank ❑ Tight Tank
❑ Other(describe):
Tee Filter 144
4. Effluent Te F r resent? ❑ Yes (�' if es, was+t cleaned? Yes No,
p Y ❑ ❑
5. Condition of System:
6: System Pumped By:
Neil.Bates-on ` F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Loc4orrwb7re „nnt ents were disposed:
C L S: , Lowell Waste Water
Sign a I Haule mate
j 0=4.dor.-06/03 System Pumping Record•Page 9 of 1