HomeMy WebLinkAboutSeptic Pumping Slip - 804 FOREST STREET 12/28/2016 Commonwealth of Massachusetts
City/Town of RECEIVED
System Pumping.Record M�� �� b 01
Form 4
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DEP has provided this form for use-by local Boards of Health. Other formsl may e� � �-I-
p Y y�e 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 forth 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 I Right front of house, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address (�
City/Town State Zip Cone
2. System Owner.
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Name*_..
Address(if different from location)
City/Town State )p ( Zip Code
Telephone Number \\\ rl / 4
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h
.B. Pumping Record
1. Date of Pumping D to 2. Quantity Pumped: ---
Gallons
3. Type-of,system`: ❑ Cesspool(s) V Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes No,
5. Condition of System:
6: System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company _.,._..,._..,._
7. Location where contents were disposed:
G,- &R.", Lowell Waste Water
Sign a Haule Date t f
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