HomeMy WebLinkAboutSeptic Pumping Slip - 623 OSGOOD STREET 12/2/2015 Commonwealth of Massachusetts
City/Town o .
y tm 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 f idMt front of housii;)Left/Right rear of house, Left/right side of house, Left/
Right side of building, tWrRii§g rant o building, Left/Right rear of building, Under deck
. Address
CityfTown Q j State Zip Code
2. System Owner:
V
Nam_e0 Ap-
Address(if different from location)
/"N ` r
Cityfrown ' State , t Co e ;
Telephone Number
B. Pumping ,Record
1. Date of Pumping Date 2. Quyntity Pumped: Gallons —�
3. Type-of system: ❑ Cesspool(s) E3SeptIc Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes ET 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
7. Location(,here contents were disposed:
G L S. Lowell Waste Water
sig—nit4e cf Haule w Date
t5form4.doc-06103 System Pumping Record•Page 1 of 1