HomeMy WebLinkAboutSeptic Pumping Slip - 450 BOSTON STREET 5/24/2017mim 2 4 701
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Form 4 TO
DEP has provided this form' for use.by local Boards of H:atl'ithLI.I'IODtEhPekrRfroMrEmNsT may be 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 for'', they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
City/Town of
Commonwealth of Massachusetts CEIV
yste P orig.
A. Facility Infor
,!, I
aflon
nor
1
1. System Location: Left / Right front of house, Left / Right rear of hou
gt-OicieOf hot
Right side of building, Left / Right front of building, Left / Right rear of u ding, UndeiTea
2. System Owner:
A
Name'
Address (if different from location)
City/Town
Telephone Number
p
1. Date of Pumping
ecor
-(7
2. Quantity Pumped:
Date Gallons
3. Type of system 0 Cesspool(s) afeptic Tank 0 Tight Tank
E} Other (describe):
4. Effluent Tee Filter present?
Condition of System:
No If yes, was it cleaned?
vl_
S Li NO
6. System Pumped By:
Batesbn •
Name
Bateson Enterprises Inc
Company
7. Location.whe e contents were disposed:
Lowell Waste Water
Ala
F5821
Vehicle License Number
Signtufe q Hauler( Date
t5form4.doc. 06/03 System Pumping Record * Page 1 of 1