HomeMy WebLinkAboutSeptic Pumping Slip - 485 FOSTER STREET 11/17/2015 Commonwealth of Massachusetts
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 Location: Left/Right front of house,(]:eb Rig us ear of ho , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address ,� '..�-' -� �,��•°;�''�-,�--
State Zip Code
CitylTown
2. System Owner. %�4
Name
Address(if different from location)
State `j Zip Code
Cityrrown 1 �0`
s Telephone Number l
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) D-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ Na
5. Condition of.System' � Q P °
6. System Pumped By:
Neil.Bates ri F5821
Name Vehicle License Number
_Bateson Enterprises Inc-
Company
7. Locat(grwhere contents were disposed:
ISign AH Lowell Waste Water
Date
System Pumping Record•Page 1 of 1
t5form4.doc•06/03