HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 380 BOXFORD STREET 4/28/2021 Commonwealth of Massachusetts AP �,�o
City/Town of R 2 g
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System Pumping Record ro&�FNORN q r°°V
Form 4 rH
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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,. l Rig rear of house, Left/right side of house, Left
Right side of building, Left/Right front of builfiing, Left Mght-raa�of building, Under deck
Address
Citylrown State Zip Code
2: System Owner. �� >
Name
Address(if different from location)
Citylrown State
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) 0-5`eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ld'No 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. Lpcatiorrvtre contents were disposed:
G L S Lowell Waste Water
Sign a Haul Date
t5f6rm4.doa 06/03 System Pumping Record•Page 1 of 1