Loading...
HomeMy WebLinkAboutSeptic Pumping Slip - 1659 OSGOOD STREET 1/29/2018 Cwe ommonalth of Massachusefts City/Town of Sy.4tem Pumping, rd Of � Form 4 DEP has provided this form for use-by local Boards of Health. Other forms maybe*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 fro the local Board of Health or other approving authority. A. Facflity. I for fl 1. SVitem Location: Left/Right front of Mouse, Left I Right rear of house, Left/right side of house, Left Right side of building, Left I Right front of building, Left/Right rear of building, Under deck Address m Cwn own ' State Zip Code 2. System Owner: ' Name' Address(if different from location) Chyli own State ,., Zip Code -,> ( � e-..d p Telephone Number �4 _. f ® Pumping Rpeord hs,m. ---- 1. date of Pumping 2. Quantity Pumped: I Crate Gallons 3. Type-of s sternCesspool(s)ls) ' �-'Sap"qc Tank E] Tight Tank ; ® Other(describe): 4. Effluent Tee Filter present? © Yes EJ-No ,. If yes, was it cleaned? [ Yes ❑ NQ 5. Condition of System- 6: System Pumped By: Neil.Bateson . F5621 [dame Vehicle License Number Bateson Enterprises Inc- Company ti„ here contents-were disposed: 7. Loca Lowell Waste Water f Sign a cf Houle Dat . WbrmCdoc^06/03 System Pumping Record.Page 1 of 1