HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 326 FOREST STREET 10/30/2019 Commonwealth of Massachusetts RECEIVED
City/Town of OCT 3 0 2019
System Pumping Record TowN o�r10RI 1 ANDOVF'
Form 4 HEALTH DEPARTr1
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 : Left/-ti front of house, Left/Right rear of house, Left/right side of house, Left
Right side of bull ing, Left/ tg ron of building, Left/Right rear of building, Under deck
9
Address Q
CiWrown State Zip Code
2. System Owner.
Name
Address(if different from location)
Cityrrown State Zi
Telephone Number
B. Pumping Record
is
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) ❑Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? es ❑ No If yes, was it cleaned? No
5. Condition of Y1 uk�� � n 1 _(}
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca -where contents were disposed:
MS. � Lowell Waste Water
Sign Data
t5form4.doc-06/03 System Pumping Record•Page 1 of 1
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