HomeMy WebLinkAboutSeptic Pumping Slip - 24 FARNUM STREET 8/21/2017 Commonwealth of Massachusetts
Gitji/Town of
7.
,System P''lumping.Record *a ,
Form 4
DEP has provided this form for use>by local Boards of Health. Other forms may be't ;;,buf the
information,must be substantially the same as that provided here. Before using.this form,check with your j
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. Inform' atlon
1. System Location: Left/Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left I Right front of building, Left 1 Right rear of building, Under deck
Address
CRY/Town State Zip Code
2: System Owner:
Name`
Address(if different from location)
l
Cityrrown Stater� ode
ce
F Telephone plumber r`fit
. Pumping Kecord
1. Date of Pumpingdate / 2. Quantity Pumped: Gallons
3. T e•of s stern: `
Yp Y. ® Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
" 5. Gondifiion of ste
6. System Pumped By:
Feil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatio a contents-were disposed:
f
iL S: Lowell Waste Water t
•
�-- c C 7
Sign a Haule Date
0=4.doc•06!03 System Pumping Record•Page 9 of 1