HomeMy WebLinkAboutSeptic Pumping Slip - 300 FOSTER STREET 12/18/2015 i
Orn �nwealth of Massachusetts r
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• ity/Town Of .
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y� to umpin Record
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i.�Form 4 v NA �
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, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
CWTown State Zip Code
2. System Owner,
Name'
Address(if different from location)
CitylTown State y eZode ;
Telephone Number
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B. Pumping kecord �.
1. Date of Pumping Date 2. Quantit�r Pumped: Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? ® es ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Location- here contents were disposed:
G L S`.� ' Lowell Waste Water
Sign a Houle Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1