HomeMy WebLinkAboutSeptic Pumping Slip - 990 FOREST STREET 8/21/2017 Commonwealth of Massachusetts
C4/Town of
F M
u° Sy tem Pumping-RecordForm 4 00 OF W(
l
DEPAR IALOT l
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 l
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. Information
9. System Location: Loft/ ._ t front bf hiouse,>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
CPtyfrown State Zip Coote
2, System Owner:
Name'
Address(if different from location)
Cityrrown - State' Zip Code
c z 5 '
Telephone Number
1
e
. Pumping Itecorel
9. Gate of Pumping nate 2- Quantity Pumped: Gallons
3. Type-of system: ® Cesspool(s) eptic Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ® No,
5. Condition of System:
6; System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location her Contents were disposed:
C S: Lowell Waste Water
Sign a Haul Date
t5form4.doc-06/03 System Pumping Record•Page 9 of 1