HomeMy WebLinkAboutSeptic Pumping Slip - 75 FOSTER STREET 10/14/2016 . Commonwealth of Massachusetts r
City/Town of .
System Pumping-Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe`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 4411kiga:rht ont of houji, Left/Riight rear of house, Left/right side of house, Left/
Right side of building, rroni of building, Left/Right rear of building, Under deck
Address
t7 _5 - ,>
CiVTown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrawn State � , , �,�COde ,
Telephone Number
.B. Pumping record
1. Date of Pumping bate 2• Quantity Pumped, Gallons
3. Type,of system: ❑ Cesspool(s) le Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System
6: System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locatio w ere contents-were disposed:
., G� Lowell Waste Water
4
SignA Haul Date
t5farm4.doc-06/03 System Pumping Record•Page 1 of 1