HomeMy WebLinkAboutSeptic Pumping Slip - 425 BOXFORD STREET 11/10/2015 w
ssachuse
Commonwealth of Ma
tts
_ City/Town of .
System Pumping.Record
Form 4
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 Locatio . Leff Rig ont of hous , Left/Right rear of house, Left/right side of house, Left/
Right side of bui mg, Left/Right ron o building, Left/Right rear of building, Under deck
. Address
CtWTown State Zip Code
2. System Owner.
U -�
Name'
Address(if different from location)
City/Town State p Co
Telephone Number
.B. Pumping !Record
1. Date of Pumping Date 2. Quantity Pumped: canons T
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 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
7. Locati we e contents-were disposed:
G L'S: Lowell Waste Water
Signitu.fe 9t Haule Date
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