HomeMy WebLinkAbout- Septic Pumping Slip - 75 FOSTER STREET 10/2/2018 Commonwe8ifth of Massachusetts
City/Town of
0 2 ?M8
SyMem Pumpling,Record Tov"!N HU R
Form 4
DEP has provided this fbrfri for use-by local Boards 6f 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 to
the local Board of Health or other approving authority.
A. FaciRty. InforMation
I. System Location: Left gt o_�f douse
�eq 9, eft I
Left/Right rear of house, Left/right side ofhous L
Right side of building, Left Right Left Right rear of building, Under deck
• Address
cltyfrown state Zip Code
2. System Owner:
Name'
Address(if different from location)
cityrrown State zle
Telephone Number
Pumping R-9cord
1. Date of Pumping 2. Quantity Pumped: —i------
ate Gallons
3. Type-of systerW. El Cesspool($) 9--SiepilcTank [I Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yes E3-9-o If yes, was it cleaned? Yes No,
S. Condition of�System:
6.. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Loca here contents-were disposed:
G,_' S.p Lowell Waste Water
. Sign e H Datebulet/
t5fbrm4.doc-06/03 System Pumping Record-Page 1 Of 1