HomeMy WebLinkAboutSeptic Pumping Slip - 23 FOREST STREET 9/6/2016 :, Commonwealth of Massachusetts RECEIVED
City/Town of
System Pumping-Record
IK-Aum 6 PMMW NT
Form 4
DEP has provided this farm for use�by focal Boards of Health. Other forms may 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/Right front of house(Le PRig 'Oi-t—c h . , Left/right side of house, Left/
Right side of building, Left/Right front of building, Left%Right rear of building, Under deck
Address
y,
Cityfrown J State 1y Zip Code
2. System Owner,
w
Name'
Address(if different from location)
Cityfrown ' State- - Zip Code
b Telephone Number
i
•
f
B. Pumpirng Record
1. Date of Pumping hate 2. Quantity Pumped:
Gallons
3. Type-of system. ❑ Cesspool(s) a-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? No If yes, was It cleaned? ] Yes°,..� No.
5. Condition of System: ,
6; System Pumped By:
Nell.Batesan F5821
Name Vehicle Llcense Number
Bateson Enterprises Ina
Company
7. Lo on)A ere contents were disposed:
G-LS--Pj Lowell Waste Water
W6 SA. 'B z 6 a-o�
Sign We Haule Date
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