HomeMy WebLinkAboutSeptic Pumping Slip - 98 FOREST STREET 12/12/2017 .5
: Commonwealth of Massachusetts
Gity/Town of .
System Pumping-Record
b.
Form 4
p
DER has provided this form far use-by local Boards of Health. other form's may,be used,but the
information-must be substantially the same as that provided here. Before using.this form,check with your r
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. i
i
A. Fact ty. InforMation
1. System Location: Left l Right front of house, Left it rear of ho , Left/right side of house, Left I
Right side of building, Left/Right front of buildirig, Left I Right rear of building, Under deck
Address
CIWTown state - Zip Code
2: System Owner.
Name
Address(if different from location)
Citylrown Staiv-) Cone
Telephone Number r+ ;
1
.B. Pumping Record
1. Date of Pumping date 2. Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
' S. Condition of System
6. System Pumped By:
Neil,Bateson F5821
Name Vehicle License Number
Bateson Erste rises Inc
Company
7. Locati w e contents-were disposed:
p
CLS: Lowell Waste Water
ti C3
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Sign a H�uf Cate
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