HomeMy WebLinkAboutseptic tank - Septic Pumping Slip - 242 FOSTER STREET 10/1/2019 Commonwealth of Massachusetts
_ City/Town of Mo
System Pumping Record oC�
Form 4
DEP has provided this form for usez by local Boards of Health. Other forms may be used,but the
information must be substantially the same 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/Right front of house, Left(4_Righf'iear of house, Left/right side of house, Left 1
Right side of building, Left/Right front of building, LeW7! g_h rear of building, Under deck
Address
MWrown State Zip Code
2. System Owner.
�L
Name
Address(if different from location)
CiWTownCo
Stag C��R� � n:�z
Telephone Number �—
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of stem:
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents,were disposed:
G L S Lowell Waste Water
Sign a Haul Date
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