HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 537 BOXFORD STREET 8/20/2019 Commonwealth of Massachusetts RECEIVED
• City/Town of AuG 20 2019
System Pumping Record WOOF
Form 4 W_&jLTM DEF x
DEP has provided this form for use-.by local Boards of Health. Other forms may be-used,but the
information must be substantially the two 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. Facility Information
1. System Location: Left/ front of hous Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ✓ �� �X��� �����,�
cityrrown l` state Zip code
2. System Owner.
Name
Address(if different from location)
CWTown �peCad
[ l
Telephone Number
B. Pumping Record
1. Date of Pumping Dale 2. Quantity Pumped: ons �
Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ekf4o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: K)o C�� �j2A_�A R
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati a contentsr were disposed:
G L S Lowell Waste Water
signWe0buleru Date
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