HomeMy WebLinkAboutSeptic Pumping Slip - 230 FOREST STREET 3/8/2016 Commonwealth c u
City/Tow City/Town of
System Pumping, Record
Form 4
DEP has provided this ford 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 ig�aftnt of h Qus4, 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
City/Town State Zip Coale
2. System Owner. „n
Name'
Address(if different from i
Cityll own ` f State , Zip,Code
F't € t � (-;.,.,
Telephone Number
JL-.
. Pumping Rqcord
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: ® Cesspool(s) epti Tc ank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present. Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: je7:itjx_
V\,
6: System Pumped By:
Neil Meson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca' 1here contents were disposed:
G L Lowell Waste Water
Sign a Haute Date
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