HomeMy WebLinkAboutSeptic Pumping Slip - 205 FOREST STREET 5/22/2018 Commonwealth of Massachusetts RECEIVED
MCity/Town of
wi 2 .
,« Record "�Iw•iqC11r"N'b°R O1N'
DEP has provided this form for use-by local Boards 6f-Health. Other forms may be'used,but the
information,must be substantially the same as that provided here. Before using.this fora,check with your
local Board of Health to determine the form they use.The;Bystern Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Fact0ty, Inform' aflon
1. System Location: Le ft/Right frant of Mouse, Left h ar of hRu
�, Left,/right side of house, Left/
Right side of building, Left!Right front of building, Left/Righ rear of building, Under deck
Address
dy/rnwn State Zip Corse
2. System Owner.
Name'
Address(if different from location)
CitytTown Statefr i Code
�.•
Telephone Number
r
Pumping - . r
w
1. bate of Pumping crate 2. Quantity Pumped: Gallons j ,
. 4t
3. Type-of system`: ® Cesspool(s) Septic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? Ej Yes o if yes,was it cleaned? ® Yes ® No
5. Condition f System: ( r
6: System Pumped By:
Pfeil.Bateson ' P5821
Name Vehicle License Number
_Bateson Enterprises Inc,
Company
7. Loca'e „� - ere contents-were disposed:
S; Lowell Waste Water
~ E
Sign a Hauler, ®ate
t5form4.doc•06/03 System Pumping Record.Page 1 of 1