HomeMy WebLinkAboutSeptic Pumping Slip - 327 FOREST STREET 7/29/2016 : Commonwealth of Massachusetts
City/Town of � ,:
System Pumping-Record
Form
DEP has provided this form for useoby focal Boards of Health. Other farms it ay E a u§a , 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 1 Right frozit of house, Left l eat of house) Left,/right side of house, Left I
Right side of building, Left 1 Right front of building, Left 1 Right rear of building, Under deck
Address
Citylrown State Zip Code
2. System Owner.
y
Name'
Address('if different from location)
CitylTown State-� � �� �Zigs de
f
Telephone Number � 3.
i
.B. Pumping r-ocord
V � .
1, Date of Pumping 2. Quantity Pumped:
Date Gallons ry
.3. Type-of system: ❑ Cesspool(s) ❑.F is Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was It cleaned? ❑ Yes ❑ No
' 5. Condition of System: � A � •
6. System Pumped By:
_Neil.Bateso g - --- -_-- F5821
Name Vehicle License Number
Bateson Ehte rises Inc'
Company
7. =GLSQ�>ere contentswere disposed:
. Lowell Waste Water
Siangtu.fe Haul Late
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