HomeMy WebLinkAbout- Septic Pumping Slip - 770 FOREST STREET 9/24/2018 Commonwealth f Massachusetts
P O ®f
R ■�q�, of
Pumping.Form 4
DEP has provided this for'rri for use-by local Boards 61"M lth. Other forms may be bsed,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 form they use.The System pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facloty, information
1. System Locatio . >r h rM
y �1��:=1'R'g o '�f�i�uildifig,
eft/Right rear of house, Left/right side of house, Left
Bight side of building, Leff/Righ ron Left/Right rear of building, Under deck
Address
f
citylrown state Zip code
2. System Owner
Name'
Address(if different from location)
City/Town State , y Zip Code
Telephone Number "y'>
. • � r
f
. Pumping
1. Cate of Pumping 2. Quantity Pumped:
Date Gallons i.
3. Type-of system: Cesspool(s) fstl Tc ank Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ® Yet o If yes, was it cleaned? ® Yes ® No.
' 5. Condition of System:
6.• System Pumped 6y:
I
Nell.Batesbrt F5821
Name; Vehicle Lloanse Number
lateson Enterprises Ina
Company
7. Lo ti her content were disposed:
G L= Lowell Waste Water
Sign a Hijul Date
t5fbrrn4.doc-06/03 System Pumping Record Page 1 of 1