HomeMy WebLinkAboutSeptic Pumping Slip - 206 BOXFORD STREET 12/18/2015 Commonwealth of Massachusetts
City/Town of
a System Pumping Record
Form 4
i
� Ya�
t q Boards of Health. Other fo
DEP has th your h for use
information must besubsta ti substantially the same that provided here. Befor � t J
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, Leff/
Right side of building, Le Righ front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Da t6 I 2, Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ 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. Locatt'g f►o re contents were disposed:
G.L S. Lowell Waste Water
Sign to`e I HaulerU Date
f
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