HomeMy WebLinkAboutSeptic Pumping Slip - 326 FOREST STREET 10/12/2016 Commonwealth of Massachusetts
RECEIVD
City/Town of . °;m
System Pumping.Record �� p
Form 4
a-iEA r E i Dc�.i�:�°atc�r � � .F
DEP has provided this form for use4by local Boards of Health. Other forms may be used, bu 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
I. System Locatio 1 Righ ra�house Left/Ri ght rear of house, Left•I right side of house, Left Right side of building, Left/Righ lding, Left/Right rear of building, Under deck
Address
Cdyftown State Zip Code
21 System Owner
Name'
Address(if different from location)
Cityfrown state Zip code
"telephone Number
� 1
.B. Pumping Ptecord
1. Date of Pumping pate 2. Quantity Pumped: Gallons
3. Type•of system: ❑ Cesspools a tic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es 0 No If yes, was it cleaned? M-A-4� Flo,
6. Condition of System:
6; System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Loco` e contents were disposed:
G L S'. Lowell Waste Water
Tc&A
Sign a Haule Date
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