HomeMy WebLinkAboutSeptic Pumping Slip - 415 BOXFORD STREET 11/10/2015 Commonwealth of Massachusetts
City/Town of
System Pumping-Record
Form 4
DEP has provided this form for usez 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 RI , Left/Right rear of house, Left/right side of house, Left/
Right side of building, ilding, Left/Right re ar of building, Under deck
Address
�G Q
City/Town
f S ate Zip Code
2. System Owner:
Name
Address(if different from location)
Citylrown State �--3 Zip de
Telephone Number
y i
B. Pumping Record
A i 2. Quantity Pumped: Gallons
1. Date of Pumping Date _ /'
3. Type-of system: El Cesspool(s) ESI Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [ No 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
I
7. Lo to here contents-were disposed:
GL S'. Lowell Waste Water
SignAtufe 9t Haulejj Date
06/03 c• System Pumping Record•Page 9 of 1
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