HomeMy WebLinkAboutSeptic Pumping Slip - 64 FOREST STREET 9/10/2016 : Commonwealth Of Massachusetts AVED
City/Town of
System Pumping-Record
Form 4
DEP has provided this farm 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/Right front of house, Left/Right rear of house, rig k-966- ofh uses, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address �" '"
CRY/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
Cityfrown ' State Zip Code
A Telephone Number
.B. Pumping Rpcord •
1. Date of Pumping Date Z Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? ® es ❑ No.
5. Condition of Syste {„`
6. S stem um d B :
Y Pe Y
Nell.Bateson F5821
Name Vehicle license Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
Lowell Waste Water
• F
SignAtufe qt Houle Date
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