HomeMy WebLinkAboutSeptic Pumping Slip - 667 FOREST STREET 4/24/2018 Commonwealth of Massachusetts
City/Town ofSystem
x
Pumping. r
Form 4
DEP has provided this forfri for use-by local Boards of Health. father forms may be'used,but the
information-must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the forrn they use. The;System pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facift Informiatiom,
1. System Location: Left/Right front of Pious a Righ ofmous , Left/right side of house, Left I
Right side of building, Left/Right front of bu efrig, Left/Right rear df building, Under deck
Address
RY7 own state Zip Code
2. System Owner
Name
Address(if different from location)
City/Town ` sta � ,p gPAa._.
'`cam'' ✓ �
`telephone Number
Ppaipling Ripcord
1. Date of Pumping Date 2. Quantity Pumped: Gallons�.��
3. Type-of system: ❑ Cesspool(s) epfic Tank El Tight Tank
Other(describe):
4. Effluent Tee Filter present? ® Yes o if yes,was it cleaned? ❑ Yes ® No,
5. Condition of.System:po
,� �
6: System Pumped By:
Nell.Bateson F'5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7, Loca' e contentsrwere disposed:
Q Lowell Waste Water
-- F
S7ig_nFtuTe cf HbulwU date
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