HomeMy WebLinkAboutSeptic Pumping Slip - 536 FOREST STREET 5/1/2017 Commonwealth of Massachuseffs
RECEIVED
City/Town of
a
Sp4tem Pumping.Record'
ER
F �1) t � t o w x f K Aga���
DFP has provided this form for use-by local Boards of Health. Other forms may be'used, but the
information must be substantially the carne as that provided here. Before using.this farm,check with your
local Board of health to determine the forrrl they use,The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
9. Systema Location: Left/ t front oaf douse Left/bight rear of house, Left/right side of house, Left
Right side of building, Left/Right ron o building, Left/Right rear of building, Under deck
Address
city/Town state Zip Code
2. System Owner:
LC
Name
Address(if different tram location)
City/Town - State _ 9 t Cade
"telephone Plumber
r
.B. Pumping Rqcord
1. date of Pumping ole 2. Quntity Pumped:
Gallons,
. Type-of system: E3 Cesspool(s) eptic®rank D Tight Tank
Other(describe):
4. Effluent Tee Filter present? El Yep B-h-o If yes, was it cleaned? 0 Yes E3 No,
' 5. Condition of System:
6. System Pumped 6y:
Nell.Bat inn ' F6621
Name Vehicle License Number
B8!2E21FhterHises lnc
Company
7. Location here contents-were disposed:
Lowell Waste Water
L( � — C
sign a Ftaule Date
t5f6rrn4.doom 06/03 System Pumping Record Mage 1 of 1