HomeMy WebLinkAboutSeptic Pumping Slip - 121 FOREST STREET 8/22/2016 RECEIVD
Commonwealth of Massachusetts 1b
s C4/Town of .
System Pumping.Record i , 'A p�u����;�vu:e�,��
Form 4 q�i..� iu�a����wi���i�e���c..��,1"
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: Left -R gi h ont of house`1,.eft/Right rear of house, Left/right side of house, Left/
Right side of building,�t't�Rigt"It�t °of-buiidirig, Left/Right rear of building, Under deck
Address
ClWTown State Zip Code
2. System Owner.
Name'
Address(if different from location)
Citylrown State Zip cod
F Telephone Number ".
i
i
.B. Pumping Record C
1. Date of Pumping bate 2. Quantity Pumped: Gallons
3. T e•of s stem: `
Type-of y. ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep a If yes,was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Ina
Company
7. Locatio h re contents were disposed:
k L&P Lowell Waste Water
I &SA
I
-gig-nAttle I Haule bate
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