HomeMy WebLinkAboutSeptic Pumping Slip - 45 FOREST STREET 6/14/2017 Commonwealth of Massachusetts
Q . .QWTown of
Srkern Pumping.Record
Form 44 "
l
DEP has provided this form for use-by local Boards of Health. Other form's �, but the
information,must be substantially the same as that provided here. Before using. is 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. Faci-llty Information .
1. System Location: Left/Right front of Mouse, Left/Right rear of house, Left/r gsi he-oU"e, Left,/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State - Zip Code
2, System Owner. 1
Name'
Address(if different from location) t
City>Town State:. -Zi code
Telephone Number --•,
. Pum=ping Rpc rd
1. Date of Pumping Date �epficTank
Pumped: Gallons3. Type-of system. Cesspools) ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
' 5. Condition of System: /� }
6. System Pumped By:
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locatiorv,••here ontents-were disposed:
GLS; Lowell Waste Water
SignAtu Fe I Haule Date
15form4.doc•06/03 System Pumping Record•Page 9 of 7