HomeMy WebLinkAboutSeptic Pumping Slip - 1659 OSGOOD STREET 5/22/2018 Commonweialth of Massachuseffs
Cit"" own of . RECEIV
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may sed, but the
information must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Wealth to determine the fort%t they use.The System pumping Record must be submitted to
the local Board of Wealth or other approving authority.
®
cility, Infor n.
1, System Location: Left/Right front of house, Left 1 Right rear of house, Left/r gfi#ale 8 of housg Lett
Right side of building, Left J Right front of building, Left/Right rear of building, n
Address
citylrown Qj State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityrrown ' State Zip Cade
Rf ,.— 1 ,
Telephone Number
e
m Pumping.. it
,. ".
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system: Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o if yes,was it cleaned? E Yes ❑ No,
' 5. Condition of System:
s: System Pumped By:
Neil.Bateson ' E5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location where contents were disposed:
M011. Lowell Waste Water
Sign Date
tftrrn4.dat-06/03 System Pumping Record•Page 1 of 1