HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 206 BOXFORD STREET 12/12/2019 Commonwealth of Massachusetts ; �CEIVED
City/Town of 0Ec 1 2 nl1
System Pumping Record �HANoo
vER
Form 4 T4 ��H pEPAR1MENT
DEP has provided this form for use--by local Boards of Health. Other forms may 6e'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 ht rear of ho Left/right side of house, Left 1
Right side of building, Left/Right front of building, Left I Rightrear of building, Under deck
Address Doe,
City/Tom state Zip Code
2. System Owner.
Name'
Address(if different from location)
C4 Town State
Telephon-Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) c Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a_M If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: t
S. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. =LS.
contents-were disposed:
Lowell Waste Water
Sign a qt Hauwl Date
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