HomeMy WebLinkAboutSeptic Pumping Slip - 657 FOREST STREET 3/8/2016 Commonwealth
= City/Town oi City/Tow .
System Pumping-Record
Form 4
DEP has provided this form for use=by local Boards of Health. Other farms 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/ ht front of ha saf 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
Cityfrown State Zip Code
2. System Owner: S
Name,
Address(if different from location)
City/Town Stated Zip Coe ;
t
Telephone Number '
Pumping ecor
1, Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es o If yes,was it cleaned' s No,
5. Condition of System:
6: System Pumped By:
Neil.Batesan F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location here contents were disposed:
G L S. Lowell Waste Water
Sign a Haule Date
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