HomeMy WebLinkAboutSeptic System - Septic Pumping Slip - 73 FOREST STREET 10/1/2019 A
Commonwealth of Massachusetts
City/Town of
ANgpVER
System Pumping Record �oH�jNo pPRje,1EN�
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 Locatio • e —' fron�oho_u eft/Right rear of house, Left/right side of house, Left/
Right side of bu g� of building, Left/Right rear of building, Under deck
Address
Cityfrown State Zip Code
2. System Owner.
Name
Address(if different from location)
city/Town � cf--?_ �zp C
Telephone Number
B. Pumping record
1. Date of Pumping 2. Quan' mped:
Date Gallons
3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Systemj1
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
Signitufa qt Haul Date
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