HomeMy WebLinkAboutSeptic Pumping Slip - 1493 FOREST STREET EXT 5/24/2017City/Towl • •
Commonwealth of Massachusetts ECEIVE
?, 4 '/.0
yste P•u pin ecord
4EAL11.9 DLPARIMENT
4
DEP has provided this form. for use by local Boards Of Health. Other forms may bebsed, but the
information must be substantially the same as that provided here. Before using.this forrn, check with 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 Infor
1. System Location: Left Right fron of haus , eft/ Right rear of house, Left/ right side of house, Left /
Right side of building, Le /Rig ff�tiirbiiikiirig, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
Name
Address(if differentfr
City/Town
g Rec
1. Date of Pumping
3. Typeof system:
Other (describe):
lo
t on)
Date
•
Cesspool(s)
4. Effluent Tee Filter present? 0 Yes
5 Condition of System: 10
2. Quantity Pumped:
eptic Tank 0 Tight Tank
If yes, was it cleaned? Yes Ej No,
6. System Pumped By:
Nell Bateson
Name
Bateson Ent
Company
7. Locati
Sign
Inc
contents were disposed:
Lowell Waste Water
F5821
Vehicle License Number
Date
t5form4.doc• 06/03 System Pumping Record Page 1 of 1