HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 287 FOREST STREET 9/20/2019 Commonwealth of Massachusetts
= City/Town of
System Pumping Record SEP 2 0 2019
Form 4
DEP has provided this form for usezby local Boards of Health. Other forms may be'used, but the
information must be substantially the same 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. Facility Information
1. System Location: Left/Right front of house, Left/Right rear of hous(, LO-j�riqffside of house LeftRight side of building, Left/Right front of building, Left/Right rear ofmg, e
Address
c4frown State Zip Code
2. System Owner.
Name'
Address(if different from location)
CitylTown State ���Zip�ode
5
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quan. Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ; eptic
Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bates7on F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca" ere contents were disposed:
G L S Lowell Waste Water
SignAtule CfHaulWUDate
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