HomeMy WebLinkAbout- Septic Pumping Slip - 1659 OSGOOD STREET 10/31/2018 Commonwealth of Massachusetts
City/Town of OC,,T 3
YJ � ury
System ffing Record TOMI OF
Form 4
DEP has provided this farm 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 usin .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 Inform' ation
1. System Location: Lek/Right front of douse, Left I Right rear of house, Leff I right side of house, Left 1
Right side of building, Left/Right front of buildirg, Left/Right rear of building, Under deck
Address it
( .E
city/rown 79tate Zip Code
2. System Owner:
Name*
Address(if different from location)
cityrrown Stat ip Cade
`telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: El Gesspool(s) eptic Tank [I Tight Tank
Other(describe):
4. Effluent Tee Filter present? E] Yes No If yes, was it cleaned? ® Yes ® No
5. Condition of Syste ;
6. System Pumped By:
Nell.Bates0 F 821
Name Vehicle License Number
_Bateson Enterprises Ina
Company
7, Locati re content were disposed;
Lowell Waste Water
Sign a wliaul Date
t81orm4.doo°06/03 system Pumping Record o Page 1 of 1