HomeMy WebLinkAboutSeptic Pumping Slip - 704 FOREST STREET 10/20/2016 i
'A-_ , Commonwealth of Massachusetts �
City/Town of
System Pumping.Record �''
Form 4 �r`r��,f,, � .
`•Cud r'��k
DE has provided this form for use-by local Boards of Health. Other form's 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 forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Locatio,,'�~ Rlg ro f hoes , Left I Right rear of house, Left I right side of house, Left/
Right side of b lltS di Left/Right front of building, Left/Right rear of building, Under deck
9 9 9 9 g.
Address
M
cVrown State Zip Code
2. System Owner. �
Name
Address(if different from location)
C'i frown tea^ Code,
tY State "1
Telephone Number .
.B. Pumping Ri� cord w
1. Date of Pumping 2. Quantity Pumped: --=
Late Gallons
3. Type-of s Ystem: D Cesspool(s) ❑ 'ge ticH~..,.
Tank [I Tight Tank .
Other(describe):
4. Effluent Tee Filter present? ❑ Yep If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System•� VV _
6. System Pumped By:
Neil.Bateson ' F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca ' n~w ere contents were disposed.
G S Lowell Waste Water
Sign a Haule Date
t5f6rm4.doc.-06/03 System Pumping Record•Page 9 of 1
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