HomeMy WebLinkAboutSeptic Pumping Slip - 206 BOXFORD STREET 12/13/2017 : Commonwealth of Massachusetts
CitY/Town o .
System Pumping-Record
Form 4
DEP has provided this form for use-by local Boards o€-Health. Other forms may be'used, but the
information,must be substantially the same as that provided here. Before using.this farm,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 Inform' a#ion
1. System Location: Left/Right frorit of douse, Left 1 tg reams u , Left/right side of house, Left I
Right side of building, Left/Right front of buildirig, Le !grear of building, Under deck
Address O 4�1 `�G�? `�1� lam•
CityfTown state Zip Code
2. System Owner
Name.'
Address(if different from location)
CitylTown Stat £ 9 Zip yodel f r
"telephone Number
.B. Pumping record
1. ®ate of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system. ® Cesspool(s) eptic Tank ® Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ Na
b. Condition of System: _
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Este rises Inc
Company
7ISIgon
je
here contents-were disposed:
: Lowell Waste Water
F
HDate •
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