HomeMy WebLinkAboutSeptic Pumping Slip - 1659 OSGOOD STREET 10/26/2015 o
Commonwealth of Massachusetts
City/Town of 1
System Pumping-Record
Form 4 f
' 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.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location. Left/1ti ,r M m
y' gt e,ht of hou§a, Left/Right rear of pause, Left/right side of house, Left/
Right side of bul g, Left/ g ron o building, Left/Right rear of building, Under deck
�Address � _. "
Citylrown state Zip Code
2. System Owner.
Name
Address(if di frofn cation)
' Zip Cade '
Ci /rown State
ty �°" '�"' _- t
Telephone Number ,
ti i
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? [I w Yep No if yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: UAJ
6: System Pumped By: EC "J
Neil,Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc, TOWN OF Nor', ;JVEP
Company 'KAI .fl1 DL m n MENT
7. LogRtio7A�ere contents were disposed:
G L SMHaule Lowell Waste Water
.� x �, .
Sign Date
0orm4.doc•06/03 System Pumping Record•Page 9 of 1