HomeMy WebLinkAboutSeptic Pumping Slip - 206 BOXFORD STREET 12/17/2015 i
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 d, 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
I. System Location: Left/Right front of house, Left r[Rgt rear of haus , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
��(�� �C��X �-ref.G�. �°�_ ,� • `� (�`v6
City/Town state Zip Code
2. System Owner:
L02 Le C
Name
Address(if different from location)
Cityfrown State //y( 1+ /Zip Code
Telephone Number
a 1
_ !r
B. Pumping record
1. Date of Pumping Da
✓ M_ 2. uantity Pumped: Canons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
Mr)(,M C',
6: System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locati9n.w.ere contents were disposed:
,L S- Lowell Waste Water
4f
Signitufe Haule Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
i