HomeMy WebLinkAboutSeptic Pumping Slip - 64 FOREST STREET 8/21/2017 Commonwealth of Massachusetts
_ CiWTown of . RECEIVED
Sy.4teim (Pumping-Record
Form 4
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T'°� Tti fikiir,)
DEP has provided this for' for use-by local Boards of-Health. Other forms may,&I�uWAQ"P7
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.
1
A. Facility. Information
1. System Location: Left/Right front of house, Left/Right rear of house, Left/ ht side of house eft/
Right side of building, Left/Right front of building, Left/Right rear of building, Under dec
Address
CitylTown State Zip Code
2. System Owner: � .
Name
Address(if different from location)
Citylrown - State- Zip Code
Telephone Number > ;
. Pumping record
O� '
1. Gate of Pumping Date 2. Quantity Pumped: Gallons :ter
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ es ® No if yes, was it cleaned? [a- ® No
6. Condition of System:
G" c {.,.J � ., ti�.
6. System Pumped By:
Neil.Bateson - F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Locati b, re contents�were disposed:
G t_S: Lowell Waste Wafer
If L-f
_ F
Sign a Haul Date
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