HomeMy WebLinkAboutSeptic Pumping Slip - 45 FOREST STREET 6/24/2016 4\- Commonwealth of Massachusetts RE"CEIVED
i wn of
t . Pumping.Record-
Form 4 qqyy oo Vvff CC t Y t pv
DEP has provided this form for use;by focal 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. Infor ati n
1 Right side of building, Left/Right front of building, Left/Righ-fre F-&6 iIdi/right side of house, Left/
System 9 g _.
ar of building, Under deck
Address
� f~
C" !Town Stan f .
dY a Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town ' State Zip Code ;
1
N �' .
f Telephone Number
13. Pumping , pcor
1. Date of Pumping DateC /Septic�luantity Pumped: eal Ions
3. Type-of system: El Cesspool(s) Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes . /No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Neil.Bates®n F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location where contents were disposed:
/GLLS-i Lowell Waste Water
Sign a qt Haule Date
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