HomeMy WebLinkAboutSeptic Pumping Slip - 230 GRAY STREET 1/11/2016 1
Commonwealth of Massachusetts
= v • ity/'Town of .
S Y t u i rd
j
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/Right front of hous L .PRRig lee o hous. ' right side of house, Left/
Right side of building, Left/Right front of building, Left%Right rear of building, Under deck
Address
Citylrown state TIP Code
2. System Owner:
Name'
Address(if different from location)
City/Town ' $tat
1� " C Zip Code
Telephone Number ;
3
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B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type s stem:
yp y• ❑ Cesspool(s) ® Septic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil,Bates-on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo on-where,contents were disposed:
G L S: � � Lowell Waste Water
Sign a Hauls Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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