HomeMy WebLinkAboutSeptic Pumping Slip - 544 FOSTER STREET 11/8/2016 Commonwealth of Massachusetts
v . City/Town of RECEIVED
System Pumping.Record
Form 4 NOV I b /U"s u
4•
C�. N cal €a ar (-)VE
DEP has provided this farm for use>by local Boards of Health. Other forms may � 1� 4T
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/ i t front of hou Left 1 Right rear of house, Left/right side of house, Left/
Right side of building, Left ig ron o uildirig, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System owner.
Name'
Address(if different from location)
cityfrown ' State r Cam,.
Zip Cade ,
f Telephone Number f
.B. Pumping record
�C
1. Date of Pumping pate 2. Quantity Pumped:
GallonsW '
3. Type•of system: ❑ C sspool(s) eptic Tank ❑ Tight Tank
V-
® her(describe): ```�
4. Effluent Tee Filter present? ❑ Yes ®°'1iro If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System
6. System Pumped By:
Nell.Batesion ' F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Lo Bo e c ontents-were disposed:
jbar
� Lowell Waste Water
Sign a RHgule Date f
t5f6rm4.doc•06/03 System Pumping Record•Page 1 of 1