HomeMy WebLinkAboutMiscellaneous - 380 BOXFORD STREET 4/30/2018 (3).-C-\ . Commonwealth of Massachusetts
City/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 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 Information
1. System Location: Left / Right front of house, Left / Rig*' e�'�f house, Left �e'c
, Left/
Right side of building, Left / Right front of building, Left rMigght rear of building, U
Address. ,
<'_..�✓ �- �,�-(ice;
City/Town state Zip Code
2. System Owner. RECEIVED
Name' MA
Address (if different from location) �n'!�:.�V-R
HFAL'1'il G
Citylrown ' Stat Zip Code
J4
Telephone Number r
z
B. Pumping JRpcord
jt
1. Date of Pumping Date 2. Quantity Pumped:
Gallons i
3. Type of system- YP Y . ❑ Cesspool(s) Septic Tank El Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of stem:
6: System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Lova ' where contents -were disposed:
6US'. Lowell Waste Water
__j _
F5821
Vehicle Uoense Number
Date
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