HomeMy WebLinkAbout- Septic Pumping Slip - 45 FOREST STREET 3/4/2019 Commonwealthf Massachusetts
City/Town o
System Pumping Record
Form
DEP has provided this form for use-by local Boards otHealth. Other forms may be'used,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. Fi-cility InforMation
1. System Location: Left/Right front of douse, Left/Right rear of house, Left rz hg t side of house)Left f
Right side of building, Left/Right front of building, Left/Right rear of building, Under e--R—µ
Address
city/rown -- State Zip Code
2. System Owner:
Name'
Address(if different from location)
CitWTown State , Zip de
Telephone Number
® Pumpling Ptecord
f. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type-of system: Cesspools) eptic Tank ❑ Tight Tank
® Other(describe):
4. Effluent Tee Filter resent?p ® Yes o if yes, was it cleaned? El Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Batesion F5821
Name Vehicle License Number
Bateson Enter_prises Inc
company
7.jSigne
re contents-were disposed:
Lowell Waste Water
HibulpWU
Date
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