HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 624 BOXFORD STREET 9/13/2021 : R
Commonwealth of Massachusetts �c��v��
City/Town of
System Pumping Record
Y g
Form 4
DEP has provided this form for use=by local Boards of Health. Other forms may beused,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 forrh 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/Right near of house ng a of house Left
Right side of building, Left/Right front of building, Left/Right rear of bur ding, Under dec
Address
City/rown (� State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cwrownstat�g t— ��fZip Code...
Telephone Number
B. Pumping record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes O If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sjr?tern ,7
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents-were disposed:
r S: Lowell Waste Water
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Sign a it Haulev Date
tftrm4.doc-OW03 System Pumping Record•Page 1 of 1