HomeMy WebLinkAboutSeptic Pumping Slip - 720 FOSTER STREET 10/31/2016 Commonwealth of Massachusetts
City/Town of
w° System Pumping.Record )
Form 4 �
HE A�,t Vt`max4 i'1 I 6i�i i�.6v�
DEP has provided this form for use-by local Boards of Health. Other forms may be used, but the
informafi=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/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
= mm
ci yrrown State - Zip Code
2. System Owner.
r
Name`
Address(if different from location)
cityfrown State Zip Code
Telephone Number
i
.B• Pumping Record y
1. Date of Pumping p e 2. Quantity Pumped: Gallons r
3. Type-of system: ❑ Cesspool(s) Iic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? Q Yep If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System-
6.- System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents were disposed:
.L Lowell Waste Water
SignAtufe I HauleyU Date
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