HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 76 BOXFORD STREET 6/24/2021 : Commonwealth of Massachusetts
City/Town of
System Pumping Record RE�EN�O
Form 4 p11
DEP has provided this form for use-by local Boards of Health. Other forms maybe*u vti
information,must be substantially the same as that provided here. Before us* 1 with your
local Board of Health to determine the form they use.The System PumpinXShc trust be submitted to
the local Board of Health or other approving authority.
X Facility Information
1. System Location: Left/Right front of House, Left/ ear f ho sEu )Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ►�(O F'",� � � Iy��V"�`lam
Citylrown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTown State Tip e
Telephone Number
B. Pumping Record / ,D
1. Date of Pumping .Quanti Pumped: l
P g D ty P Gallons
3. Type-of system: ❑ Cesspool(s) ptic 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.jLoca" here contents-were disposed:
. Lowell Waste Water
li�ul Date
t5form4.doc-06/03 System Pumping Record•Page 1 of 1