HomeMy WebLinkAboutSystem Pumping Record - Septic Pumping Slip - 805 FOREST STREET 9/20/2019 Commonwealth of Massachusetts
City[Town of SEp 2 0 2019
System Pumping Record
Form 4
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 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: elf L Ri ig ron o front of House, Left/Right rear of house, Left/right side of house, Left
Right side of building, Left/R building, Left/Right rear of building, Under deck
Address
city/Town State Zip Code
2. System Owner.
Q
Name
Address(if different from location)
City/Town State ) ZIP code
Telephone Number
B. Pumping Record
91
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑.�c Tank
p ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Dlwo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
_L S. Lowell Waste Water
SignAtule I Haul Date
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