HomeMy WebLinkAbout- Septic Pumping Slip - 326 FOREST STREET 10/19/2018 Commonwealth of Massachusetts RECt" i'VED
City/Town of
• System Pumping Record jj 1qji)OVER
Form 4 VOW4 OF t4(JK[_ NT
UpARTME
DEP has provided this form for use-by local Boards of Health. Other forms maybe'used,but the
Information-must be substantially the tame as that provided here. Before usingthis 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. Facility InforMatlon
1. System Locatio e Rig K-Cont of hour , Left/Right rear of house, Left/right side of house, Left I
of
Right
Right side of bul�02g,?Left/Right fron;of building, Left Right rear of building, Under deck
Address
city/rown state Zip Code
2. System Owner
Name'
Address(if different from locaUnn)
CitwTown State Zi Code
4-09 P�
Telephone Number
.13. Pumping Record (C�) -( (0 __ �/�
9. Date of Pumping I --- 2. Quantity Pumped:
Date Gallons
3. Typo-of system: 0 Cesspool(s) M,3-e_pt_1cTank 0 Tight Tank
El Other(describe):
4. Effluent Tee Filter present? 0-Ye-S-6 No If yes, was it cleaned? 0 No
5. Condition of System:
6. System Pumped By:
Nell.Mason F5821
Name Vehicle License Number
Bateso i Enterprises Inc
Company
7. Location e contents-were disposed:
Lowell Waste Water
Sign a Mule Gate
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