HomeMy WebLinkAbout- Septic Pumping Slip - 242 FOSTER STREET 9/24/2018 CommonweWth
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mSy,4tem Pumplln§-Record
Fora 41
DEP has provided this fbim for use-by local Boards� 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 forth they use.The System Pumping Record must be submitted to i
the local Board of Health or other approving authority.
A. Facfl!ty In or aflom.
1. System Location: Left/Right front of douse, Left/ o )Left/right side of house, Left
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
r
Address
c1ty/Town State Zip Code
2. System Owner
Name" ]
Address Of different from location)
City/Town - State/ Zip .
J7 `-g
'telephone Number
u , ire
1. Cate of Pumping crate 2. Quanti umped: Gallons a
3. Type-of system; Cesspools) eptic Tank ❑ Tight Tank i
❑ Other(describe):
4. Effluent Tee Filter present? ® Yet 9,1410 If yes, was it cleaned? ® Yes ® No,
6. Condition of System: ` V\/
6: System Pumped By:
Neil.Batesbn • F6821
Name Vehicle Ltcense Number
13ateson Enterprises Inc'
Company
7. Lotio e contents-were disposed: t
. S Lowell Waste Water t
. d
Sign a Hhul Cate
t51orm4.doc$06/03 System Pumping Record•Peg'e 1 of