HomeMy WebLinkAboutSeptic Pumping Slip - 23 FOREST STREET 10/16/2017Commonwealth of Massachusetts
City/Town of
System Pumping. Record
Form 4
• •
DEP has provided this form. for use44, local Boards of Health. Other f9
information must be substantially the same as that provided here. Befor
local Board of Health to determine the form they use. The System Pumping
the local Board of Health or other approving authority.
CEIVE
Oa 7 (5'2017
atheised, but the
ck with your
submitted to
. A. Facility Information
1. System Location: Left / Right front of !lout 4J Rig rea?ofhou e, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear cif building, Under deck
City/Town
2. System Owner:
State
Name'
Address (if different from location)
City/Town
State
Telephone Number
B. Pumping Record
1. Date of Pumping
3. Typeof system': 0• Cesspool(s)
0 Other (describe):
t6).-3
Date
2. Quantity Pumped:
D Tight Tank
4. Effluent Tee Filter present? 0 No
. Condition of System: A
If yes, was it cleaned?
[D-1-&-slefiNo,
6: System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location w);ier contents were disposed:
Lowell Waste Water
Signtufe Haule
F5821
Vehicle License Number
' 06/03 System Pumping Record • Page 1 of 1