HomeMy WebLinkAboutSeptic Pumping Slip - 61 FOREST STREET 11/16/2017 Commonwealth of Massachusetts RECEIVED
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a . City/Town of
F Sstern Pumping-Record
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®fort 4 HEALTH DEP TRT�.1�T
DEP has provided this form for use-by local Boards o€Health. Other forms may be'used,but the
information,must be substantially the same as that provided here. Before using Ahis form,check with your t
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
I. System Location: Loft/Right front of house a Ig teat of hour~ , Left/right side of house, Left/
Right side of building, Left/Right front of bul dirig, Left/R gh rear of building, Under deck
Address
city/ own State Zip code
2. System Owner.
tdame"
Address(if different from location)
city/rown State 2t 0
Zip d
Telephone Number
.B. Pumping Rq cord
1. Cate of Pumping date 2. Quantity Pumped: '
Gallons
S. Type-of system: ® Cesspool(s) Tank Tight Tank
[j Other(describe):
4, Effluent Tee Filter present? 0 Yeso If yes, was it cleaned? ® Yes n No
' S. Condition of System: .
1
6. System Pumped By: j
Nell.Bateson - F5821
Name Vehicle License Number
Bateson_ Enterprises Inc-
Company
7. Locaf on_w( a contents-were disposed:
G S. Lowell Waste Water j
SignAqt Houle Date
t5farrn4.doc•06/03 System Pumping Record;Page 1 of 9