HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 193 BOXFORD STREET 10/12/2021 p D
Commonwealth of Massaohuse tts
City/Town of oCt
System Pumping Record TO�OFNORTPAZMENTER
Form 4 H�,tTHOEP
DEP has provided this form for use-by local Boards of Health. Other forms maybe bsed,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/ t rear of ho , Leffi/right side of house, Left/
Right side of building, Left/Right front of building, Le g rear df building, Under deck
Address 1 Q 3 G -� 0_
cwrown State Zip Coda
2. System OWner.
Name'
Address cif different from location)
Ciwown State 1 Zip 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 0-1 o if yes, was It cleaned? ❑ Yes ❑ No
5. Condition of System: - L
6. System Pumped By:
- l F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locafi3p where contents were disposed:
S Lowell Waste Water
Sign a ule, Date
5form4.docr 06/03 System Pumping Record•Page 1 of 1