HomeMy WebLinkAboutSeptic Pumping Slip - 333 FOREST STREET 5/20/2016 : Commonwealth of Massachusetts
= City/Town of .
System Pumping-Record
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: Le front of douse,Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right fron o uildirig, 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 Date 2. Quan ity Pumped:
Gallons L T
3. Type of system: ❑ Cesspool(s) eptic Tank El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep 040 If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:1 1
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location w h re contents-were disposed:
GLILS-k Lowell Waste Water
3.
Sign a Haule Date
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