HomeMy WebLinkAboutSeptic Pumping Slip - 46 FOSTER STREET 5/24/2017Corn onwealth of Massachu
EIVE
City/Town of
Fo4 lli;:l' / 4 ? (I 1 I
yste P pin • . ecis rd
.
DEP has provided this form for usetty local Boardso Hea th Otherforms may be used, but the
10Nur:1 ri.
information must be substantially the same as thatttpEArOviiidDeEdPAhReTrMNBTefore using.this form, 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 nfor
atiop
1. System Location: Left / 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
2. System Owner:
Name.
Address (if dfferent from lo ti n)
City/Town
1. Date of Pumping
TelephoneNumber
2. Quantity Pumped:
Zip Code
3. Type of system': El Cesspool(s) ptic Tank El Tight Tank
ID Other (describe):
4. Effluent Tee Filter present? 0 Yes
Condition of System:A )
NO CAk,
N
6: System Pumped By:
Neil. Batesbn
Name
Bateson Enterprises Inc
Company
7. Loc cu-whee contents were disposed:
at. s. Lowell Waste Wat
Sign e. Haule
If yes, was it cleaned? D Yes Ej No,
F582
Vehicle Llcense Nu
Da
t5form4.doc. 06/03 System Pumping Record Page 1 of 1