HomeMy WebLinkAboutSeptic Pumping Slip - 98 FOREST STREET 9/29/2016 Commonwealth of Massachusetts
x City/Town of
S stem Pum in " Record
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Form 4
DEP has provided this for m for use�by local Boards of Health. Other forms ri'la��be'f� asi, 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 s Righfi . Left,/right side of house, Left I
Right side of building, Left/Right front of bu Left/Right rear of building, Under deck.
Address
City/Town State Zip Code
2. System Owner. �� � � •
Name.
Address(if different from location)
CitylTown - State,�".. r�Gode ;
Telephone Numbers
r
.B. Pumping Record
1. Date of Pumping gate 2. Quantity Pumped; Gallons
3. Type-of system" ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of Syst
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca'e here contents-were disposed:
G L S: Lowell Waste water
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'SIgnAtu.re 9t Haule Date
t5form4.doc*06/03 System Pumping Record•Page 1 of 1