HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 380 BOXFORD STREET 4/23/2020 Commonwealth of Massachusetts RECEIVED
City/Town of APR 21 2020
OF:NORIH
System Pumping Record 706EEkLTHDEPARTME T PNUU\IER
Form 4 H
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: Left/Right front of house eft/6tig rear of house eft/right side of house, Left/
Right side of building, Left/ Right front of bui ing, Left ar of building, Under deck
Address c_�
7 S6 ` c Kc
KAlf
CiWrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Citylrown State ^ _---Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) lc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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. ZSigne
e contents-were disposed:
Lowell Waste Water
Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1