HomeMy WebLinkAboutSeptic Pumping Slip - 623 OSGOOD STREET 12/7/2017 Commonwealth of Massachusetts
Uty/Town of .
System Pumping-Record
Form 4
DEP has provided this form for use.by local Boards of Health. Other forms may-be'used, but the
information•must be substantially the same as that provided here. Before using.this€orris,check with your
local 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. Faci ft, lnforMa#ion
1. System Location: L6tq fight front of hou Left/Right rear of house, Left I right side of house, Left I
Right side of building, Left i n of building, Left I Right rear df building, Under deck
. Address
Cwrown (�7 State - Zip Code
Z. System Owner: ,
Name'
Address(I different from location)
CilyTrawn ' State's ��Zip de ;
Telephone Number
f
.B, Pumping Keeord
1. Date of PumpingData 2. Quantity Pumped:
Gallons r
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
' S. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle license Number
Bateson Enterprises Inc-
Company
ncCompany
7. Locafi are contents•were disposed:
GL -P Lowell Waste Water
S!
gnAtute I Hau1 Date
0arm4.doc-06103 System Pumping Record•Page 4 of 1