HomeMy WebLinkAboutSeptic Pumping Slip - 434 BOXFORD STREET 8/15/2018 CommonwealthREcraivED
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Pumping.Record
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DEP has provided this fora i for use.by local Boards of Health. Other forms may be'used,but the
Information,must be substantially the tame 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 t(:)
the local Board of Health or other approving authority.
A. Facflity Int o r . l r i
1. System Locatio . L i Ig"Right
of Nous , Left J Right rear of house, Left J right side of house, Left/
Right side of bur ' , Left/ on of bulldirig, Left J Right rear of building, Under deck
. Address
Cityrrown state Zip Code
2. System Owner.
Mame'
Address Of different from location)
City/Town ' state Zip Code
Telephone Number
Pumpling
1 Rqcord
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of s sterni:
YP Y. Cesspool(s) eptic Tank 0 Tight Tank
Other(describe):
4. Effluent Tee Filter present? Yes o If yes, was it cleaned? Yes ® No,
5. Condition of,System:
6. System Pumped By:
HeIL Satesbn - F5821
Mame Vehicle License Number
_Bateson Enterprises Inc,
Company
7. Locaticontents were disposed:
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Lowell Waste Water
Sign a Fthule Crate
t5form4.doc"06/03 System pumping Record•Mage 1 of 1