HomeMy WebLinkAboutSeptic Pumping Slip - 754 FOREST STREET 8/1/2016 _ Commonwealth of Massachusetts
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w° 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 forrh 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/Right front of House, Left I Right rear of house, Le h side of hous )left I
Right side of building, Left 1 Right front of building, left I Right rear of building, UnTe did
Address
CWrown State - Zip Code
2. System Owner.
Name'
Address(of different from location)
cityrrown Stat1e�^• � � ip Code
3 Telephone Number t3.
1
.B. Pumping Kecord _
• ��- ���� � -=ter�`
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
.3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? 0 Yes No If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
6: System Pumped By:
Neil.BatesOn F5821
Name Vehicle License Number
Bat @Son Ehter'l]ri5es Inc-
Company
7. Loca' he contents-were disposed:
G L S: Lowell Waste Water
F
Sign a Hauie Date
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