HomeMy WebLinkAboutSeptic Pumping Slip - 206 BOXFORD STREET 12/28/2016 Commonwealth f Massachusefts
RZECEIVED
w 4 of .
SyMem Pumping.Record
lip
Form 4 "I'M U-
fl
DEP has provided this form far use�by local Boards of Health. Other forms maybe used, but the
information must be substantially the tame as that provided here. Before using.this farm,check with your
loc6l Board of Health to determine the forrh they use. The system Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility, Information
I. System Location: Left/Right front of house, Left/ fight rear of hau , Left/right aids of house, Left
Right side of building, Left/Right front of building, Le fig rear of building, Under desk
Address
City/Town State Zip code
2. System Owner:
Name'
Address(if different from location)
City/Town Stata �7e dip co e ;
Telephone Number
,B. Pumping i
r
t. bete of Pumping cote 2. Quantity Pumped: Gallons
. Type-of systerra: Cesspool(s) 0,86ptic Tank D Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yep o If yes, was it cleaned? 0 Yes El No
' S. condition of system:
6: System Pumped 6y:
Nell.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lo Cie re contents,were disposed:
L S: Lowell 1Naste Water
- F
Sign a Hauie Date
t5form4.docm 08103 System Pumping Record-Page 1 of 1
