HomeMy WebLinkAboutSeptic Pumping Slip - 327 FOREST STREET 8/21/2017 Commonwealth of Massachusetts
C4/Town of
�- Ot+em P'-umpin .Record '
Form.4
DEP has provided this form-for use-by local Boards of Health. Other forms may-be'used,but the
information-must be substantially the same as that provided here. Before 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 Inforrtiation
I. System Location: Left/Right front of house, Left rear stLttro , 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 State Zip Code
2'. System Owner:
Name'
Address(if different from location)
City/Town ` Staten_ Zi re.
Telephone Number
. Pumping Racolyd
1. Gate of Pumping Date 2. Quantity Pumped: � �
Gallons
3. Type-of system: [j Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
' 5. Condition of System:
6. System P rnped By:
Neil.Bateson F5821
Name Vehicle License Number {
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
_L S: Lowell Waste Water 1
SignAqe cf Haul late
Morm4.doc*06/43 System Pumping Record•Page 1 of i