HomeMy WebLinkAboutSeptic Pumping Slip - 1000 FOREST STREET 5/15/2017 Common t [t fMassachusetts
45)
City/Town of .
aS *tem l r
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe'used, but the
informedon must be substantially the tame as that provided here. Before using.fhis form,check with your
local Board of Health to determine the forrh they use. The System pumping Record must be submitted t
the local Board of Wealth or other approving authority.
A. Facifity. Infos tion
I. System Location: Left/Right front pf douse, Left]Right rear of hoes. L f ►rig i o hoes Left/
5 Right side of building, Left/Riglit fr6nt of building, Left/Right rear of building, UnMr e"
Address
city/rown State Zip code
2. System Owner:
Name*
Address(if different from location)
cityrrown Stater _ ZJP Cade
Telephone Number �
v �
m PuMpIng Rgeord
1. Date of Pumping bete 2. entity Pumped: eltons
Type-of system: 0 Cesspool(s) Tank El Tight Tank
El Other(describe):
4.. Effluent Tee Filter present? El Yes Wo If yes, was it cleaned? E Yes No,
5. Condition of Syst rn:
6. System Pumped By:
Nell.Bat on F6821
Nerve Vehicle License Number
Bateson Enterprises Inc'
Company
7. Lo ti ere contents were disposed:
Lowell Waste Water
sign a Nauie Clete
i5tbrrn4.doc®06/03 system Pumping Record Page I of 1