HomeMy WebLinkAboutSeptic Pumping Slip - 895 FOREST STREET 10/21/2016 Commonwealth of Massachusetts
.
City/Town of . .- . .
System Pumping-Record
Form 4
OCT ,wj � �'
DEP has provided this form for use-by local Boards of Health. Other forms may bbt�iar ov
information'must be substantially the same as that provided here. Before usingNiss
, dirwtit 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 Location: Left/Right front of house, Left 1 Right rear of house, Left/11" t side of houseLeft 1
Right side of building, Left/Right front of building, Left/Right rear of building, Unc` ci"`"""-'
Address s
City/Town State Zip code
2. System Owner:
Name
Address(if different from location)
City/Town ' State p Code , .
Telephone Number
.B. Pumping JRacord
1. Date of Pumping .2. Quantity Pumped: Gallons --`
3.
Type-of s
Yp stem:Y, ❑ Cesspool(s) [D--8 pti�'T k F1 Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes a If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System: J
6: System Pumped By:
Nell.Bates ri F5821
Name Vehicle License Number
Bateson Enterprises Inc'
Company
7. Loca ' re contents were disposed:
G L S: Lowell Waste Water
Sign a qf HaulerU Date
t5form4.doo-06/03 System Pumping Record•page 1 of 1