HomeMy WebLinkAboutSeptic Pumping Slip - 207 BOXFORD STREET 12/26/2017 Commonwealth of Massachusetts ay;;
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Sy.4tefn Pumping-Record
Form 4
. 1
DEP has provided this form for use-by local Boards ofHealth. Other forms 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 form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility InforMa- tion
1. System Location: Left/Right front of Mouse,�'e PRigh ear of ho e, Left/right side of house, Left/ f
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck f
Address j
City/Town State Zip Code
2. System Owner.
Name"
Address(if different from location)
City/Town ` State Zip Code
Y
Telephone Number
i
r
A
Pumping Rgcord
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type•of system. E] Cesspool(s) Eltl Ta,.rk Tight Tank f
® Other(describe):
4. Effluent Tee Filter present? El Yes EF'Mo- if yes, was it cleaned? ( Yes ❑ Na
6. Condition of System:
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Locafion here contents-were disposed:
C4Hule
". Lowell Waste Water t
F
Sign Date
t5form4.doo-08/03 System Pumping Record a Page 9 of 1