HomeMy WebLinkAboutSeptic Pumping Slip - 805 FOREST STREET 11/17/2017 . Commonwealth of Massachusetts BC ": E
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System Pumping-Record ToWq 01,igc)fgxTl-WDOVER
Form 4 HEALTH bEPARTMEW
DEP has provided this form far use-by local Boards of Health. Other forms maybe used, but the
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.
A. Paci ft. Inform' ation
1. System Location. ft Right rant of house, ft/Right rear of house, Left/right side of house, Left/
Right side of buil , Left/Ri uildirig, Left/Right rear of building, Under deck
Address _
City/Town State Zip Code
2. System Owner.
Name'
Address(if different from location)
City/Town ' StateZip Code
Telephone Number
Pumping Racor '
( 7 /5 '
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type-of system: Cesspool(s) ptic Tank El Tight Tank
® Other(describe):
4. Effluent Tee Filter present? ® Yes o If yes,was it cleaned? ® Yes ® No,
5. Condition of System:
('eu't c,
6: System Pumped By:
Nell.Bateson " F5821
Name Vehicle License Number
Bateson Enterprises Inc,
Company
7. Location re contents-were disposed:
L S. Lowell Waste Water
Sign A9tHiauleVDate
. t
6form4.doc-06/03 System Pumping Record•Page 1 of 1