HomeMy WebLinkAboutSeptic Pumping Slip - 220 BOXFORD STREET 10/26/2015 i
Commonwealth of Massachusetts
City/Town of 1
u° System Pumping-Record
Form 4
• I
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.Tire 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 rear of hour Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
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Address �,� / 7,� G� .-..
Cityfrown State Zip Code
2. System Owner. ,
Name
Address(if different from location)
cityrrown State' S,,,- C ip Code ;
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Telephone Number '
t
K ;
B. Pumping Record ,
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) ® Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes M. No If yes, was it cleaned? D Yes ❑ Noy
5. Condition of System-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number " so
Bateson Enterprises Inc 1,,,,�
Company TOWN of,IV
7. Locati her contents-were disposed: p A cDC)V
G L S'. Lowell Waste Water
SignAtu I Fe 9f Hauie Date
t5form4.dov 06/03 system Pumping Record•Page 1 of 1