HomeMy WebLinkAbout- Septic Pumping Slip - 385 FOREST STREET 10/31/2018 Commonwealth hu � r nCl,,, �fkfED
M i own of q, p
. i pSystem Pumpina Record
DEP has provided this form for use-by local Boards of'Health. Other forms may be'used,but the
information,must be substantially the same as that provided mere. Before using.this form,check with your
local Board of Health to determine the forrh they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility InforMation
1. System Location: Left/Right front of Mouse, Lett I Right rear of housePuldi'n
righ sigh of hour , LeftRight side of building, Left/Right front of building, Left/Right rear of Undera.
Address
city/Town State zip Code
2. System Owner:
Name'
Address(if different from location)
Ci frown
Telephone Number
13. Pumping t
1. Gate of Pumping Date 2. Quontity pumped: Gallons
3. Type-of system: Cesspool(s) Septic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? [j Yes No If yes,was it cleaned? Yes No
6. Condition of System:
6. System Pumped By:
Nell.Bates7on F6$21
Name Vehicle License Number
Sateson Enterprises Inc
Company
7. Locati r contents-were disposed:
G L S: Lowell Waste Water
Sign a Whula Cate
tftrm4.doca 06/03 System Pumping Record®page 1 of 1