HomeMy WebLinkAboutSeptic Pumping Slip - 169 BOXFORD STREET 12/17/2015 Commonwealth of Massachusetts
City/Town of �
System s u pin crd
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: LeftU"� ht front of houss Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Righfront of building, Left/Right rear of building, Under deck
Address
Citylrown state Zip Code
2: System Owner.
K,(j
Name
Address(if different from location)
City/Town • State I Code
Telephone Number
;
.B. Pumping Record
1. Date of Pumping Date 2• Quan'ty Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank El 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
7. L n- ere contents-were disposed:
7S Lowell Waste Water
_5gnitufe q9tt Haule Date
t5form4.doe-06/03 System Pumping Record•Page 1 of 1
I