HomeMy WebLinkAboutSeptic Pumping Slip - 550 BOXFORD STREET 4/24/2018 Commonwealth of Massachusetts
.C4/Town of
System Pumping.Record
Form 4r.F
DEP has provided this form for use-by local Boards of Health. tither forms may be'used,but the f
information,must be substantially the same as that provided here. Before using.this form,check with your
local Board of Health to determine the farm they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
. A. Facill.ty. Information
1. System Location• e %Rigt�rofs "c, aus ae Left/Right rear of house, Left I right side of house, Left J
Right side of bull ing, Left I Right front of building, Left I Right rear of building, Under deck
Address j
Cityfrown State Zip Code'
2. System Owner.
�. y\V +
Name'
Address(if different from location)
cityrrown State;, Zip Code
Telephone Number
. Pumping Record14
1. Date of Pumping pate 2, Quantity Pumped: Gallons
3. Type"of system: ® Cess ool s
p ( ) EJis Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes,was it cleaned? ® Yes ❑ No,
5. Condition ot System:
6. System Pumped By:
Neil,Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
•� O.L S: Lowell Waste Water I
I
signkuhe I Haule Bate
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