HomeMy WebLinkAboutSeptic Pumping Slip - 450 FOSTER STREET 6/6/2018 Commonwealth of Massachusetts
RECEIVED
Cityffown of
Sy6tem Pumping.Record
" UA
SOWN "NOF i V i�1IDOVER
Form. 4DEP 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 Wealth to determine the form they use.The System Pumping Record must be submitted to
the lanai Board of Wealth or other approving authority.
A. Fadl!ty InforMation.
1. System Location: Leont of Mouse Left 1 Right rear of house, Left/right side of house, Left/
Right side of building, Left/Flight rood building, Left/Right rear of building, Under deck
Address t >^.
CityyfTown State Zip Code
2. System towner:
Name`
Address Of different from,location)
CitylTown Stater�
t Telephone Number
lin r .�. /
1. Date of Pumping Date 2. 14luantity Pumped: — ----�
Canons
F
3. Type-of system: E] Cesspool(s) �epticTank [ Tight Tank
Other(describe):
4. Effluent Tee Filter present? ® Yep o If yes, was it cleaned? ® Yes ® No,
' S. Condition of Systerr� ) �`
6: System Pumped By:
Neil.Meson ' F5621
Name Vehicle License Dumber
Bateson Enterprises Inc
Company
7. 7LG,
he contentsrwere disposed:
S Lowell Waste Water
Sign a Haul
4 Lute f
tftrm4.doc•06/03 System Pumping Record•Mage 1 of 1