HomeMy WebLinkAboutSeptic Pumping Slip - 42 FOSTER STREET 12/4/2017 Commonwealth of Massachusetts
.City/'Town of . RECE
NED
SOtem Pumping.Record
Form 4
DEP has provided this forme 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 forms,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to J
the local Board of Health or other approving authority.
A. FaclOty. InforMation
1. System Location: Left/Right front of Mouse, 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
..
City/Town State - Zip Co,a
Z. System Owner.
Name'
Address(if different from location)
City/Town Skat Cod
P "telephone Number
P'umpling Record
1. Date of Pumping bate 2. Quan Hy Pumped:
Gallons
3. Type-of system: El Cesspool(s) Septic Tank. Tight Tank ;
[ Other(describe):
4.. Effluent Tee Filter present? ® Yes ''No If yes, was it cleaned? F1 Yes ® No,
5. Condition of Syste
6. System Pumped By: {
Nell.Bateson F5821
Name Vehicle License Number 1
Bateson Enterprises Inc-
Company
i
1. Lo n-m �re contents were disposed:
/G,L S: Lowell Waste Water
- 17-7
Le
/ . I
SignAtube cf Haiule Date
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