HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 233 BOXFORD STREET 11/19/2019 �QxC weal f hus RECEIVED
ommon th o Massac efts 9 Z019
91 City/Town of N ov
System Pumping Record o�NORaHANoov
TO�,I.TN pEppRTMENT
Form 4
DEP has provided this form for use>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: L �fronofLeft/Right rear of house, Left/right side of house, LeftRight side of building, lding, Left/Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Crty/Town statue Zip
Telephone Number
B. Pumping Record
1. Date of Pumping Date ;2. Quanti ped: Gallons
3. Type�of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No
5. Condition of System: "
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatio contents were disposed:
L S Lowell Waste Water r J
—R/-rjA. .
Signit4e fllaubluDate
t5form4.doa 06/03 System Pumping Record•Page 1 of 1