HomeMy WebLinkAboutSeptic Pumping Slip - 326 FOREST STREET 5/16/2014 Commonwealth hu tt
City/Town of
o System Pumping Record
11 AY T 0 14
Form 4
id�VU6�E� fvK)f flf64�ifili�N CE
DEP has provided this form for us&by local Boards 'of Health. Oth r lbe tls �buf"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 R� ht side of building,j Left Right bueft/Right rear of house, Left/right side of house, Left/
Righ ranf of ho %se
Right g t front o ilding, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner: / p
Name
Address(if different from location)
CitylTown ' State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2 Quantity Pumped: �--�
Gallons
3. Type of system.- ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? E3 Yes No:
5. Condition of System:
0
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Location w re contents were disposed:
�Lf
S.0 Lowell Waste Water
4SIgnt Haule Date
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