HomeMy WebLinkAboutSeptic Pumping Slip - 326 FOREST STREET 10/16/2017Cornmonwealth of Massachusetts
City/Town at
System Pumping. Record
Form 4
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HLAL UL Aki MN1r
DEP has provided this form for use.by local Boards Of Health. Other forms may be Used, but the
informationmust be substantially the tame as that provided here. Before using.this forrn, 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, Information
1. System Locationigh rorTriFibuse, L ft/ Right rear of house, Left/ right side of house, Left /
Right side of building, Left / Right fr�nf&15iiEding, Left / Right rear of building, Under deck
Address
City/Town
2. System Owner:
•
State Zip Code
Name'
Add ss (if different from o tion)
City/Town
State
1—lq
Zip
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quan ity Pumped:
Date Gallons
3. Typeof system 0 Cesspool(s) eptic Tank 0 Tight Tank
Other (describe):
4. Effluent Tee Filter present? es Ej No If yes, was it cleaned? es 0 No,
•
5. Condition 0/stem:
•
6. System Pumped By:
Neil Batesbri
• Name
Bateson Enterprises Inc'
Company
7. Locati e contents.were disposed:
a S. Lowell Waste Water
Sign e Haule
F5821
Vehicle License Number
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1