HomeMy WebLinkAboutSeptic Pumping Slip - 657 FOREST STREET 3/8/2014 Commonwealth of Massachusetts
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City/Town of
System Pumping Record
Form 4
DEP has provided this ford for use by local Boards o 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 fight front of house 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 �� "m
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City/Town State Zip Code
2. System Owner .. _f....". ,
Name'
Address(if different from location)
City/Town ' State Pf
�r
Telephone Number
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B. Pumping Record ,
Da r .. .
1. Date of Pumping 2. Quantity Pumped: Lallans
3. Type of system; ❑ Cesspool(s) ®m Septic Tank ❑ Tight Tank
❑ Other(describe):
p 0--y y es
if es, was it cleaned � � s ❑ No
6.4. Effluent Tee Filter resent' e� ❑ Na Ye
Condition o ystem 02 A
6. System Pumped By: � ( _..." -
Nell BateSon F5321
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location-"greZantents were disposed:
Lowell Waste Water
Signitute Hauls Date
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