HomeMy WebLinkAbout- Septic Pumping Slip - 300 FOSTER STREET 4/3/2019 Commonwealth
s w City/ Town of, �.
System Pumping Record
e
Form 4
DEP has provided this form for use.by local Boards of Health. Other forms may be'used,but the
information•roust be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the forri°II they use.The System Pumping Record must be submitted tc)
the local Board of Health or other approving authority.
A. Factilty Inform' ation
t. System Locatio : t� ft ,. lg, f n cif hou eft/Right rear of house, Left/right side of house, Left t
Fight side of boil tog, Lett I IgYtt front of building, Left I Right rear of building, Under dock
Address
city/Town State Zip Code
2. System Owner:
Narr�e'
Address(if different from location)
City/Town State Z p
�w
Telephone Number
® Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
- Gallons
3. Type-of system: EJ Cesspool(s) eptic Tank D Tight Tank
El Other(describe):
4. Effluent Tee Filter present? es ® No If yes, was it cleaned? ®� es No
5. Condition of Syste •:
. System Pumped 6y:
Nell.Batesbn F5821
Name Vehicle Ucense Number
Eateson Erlterprlses Inc•
Company
IsSign
. ere contertts`were disposed:
s` Lowell Waste Water
a Haul bete
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