HomeMy WebLinkAboutSeptic Pumping Slip - 380 BOXFORD STREET 5/1/2017 Commonwe.altrr, ��,"�IVEI�;'
City/Town ofSyMem `
Pumping-
Form 4
®EP has provided this form for use-by local Boards of Health. Other forms may be'used, but the
information roust be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the fora they use.The System Pumping Record must be submitted to
the local Board of Health or outer approving authority.
A. Factlity. Information
1. System Lo tion: Left/Right front of house a igh ear o,ht ogs , Left/right side of house, Left/
Right side of building, Left/Rigl t frant of buil trig, Left/Rig rear df building, Under depk
Address
�fz-
Cityrrown state Zip Code
Z. System®caner:
9
Name`
Address(if different from location)
Cibi/Town State �,• ip Code
"telephone Number
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Pumping ?2
1. Cate of Pumping bate . Quantity{pumped:
Cellons
. Type-of systema: Cesspool(s) tc`Tank El Tight Tank
E] Other(describe):
. Effluent Tee Filter present? Yds ��O:� If yes, was it cleaned? n Yes [I No,
5. Condition of System:
CC ��. .
6. System Pumped 6y:
Neil.Bat on ' F5821
Name Vehicle License Dumber
_B2te�tertarises Inc'
Company
7. Lo erg contents were disposed:
L S. Lowell Waste Water
{
Sign a Houle het®
t5form4.doc-06/03 System humping Record Page 1 of 9