HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 98 FOREST STREET 11/26/2019 : Commonwealth of Massachusetts RECE�VE�
City/Town of N�� 26 2019
System Pumping Record cowN�FNORCH well,
Form 4 nA ID
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: Left/Right front of housej�&Righ f house Left/right side of house, Left
Right side of budding, Left/Right front of building, Left/Right rear of building, Under deck
Address
cftyRom State Zip Code
2. System Owner.
jC
Name
Address(Ir different from location)
CitylTawn St� � Z -ode„
Telephone Number
B. Pumping Record /
1. Date of Pumping 2. Quantity Pumped:
Date p 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 System: �-
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7.=LS.
contents-were disposed:
W Lowell Waste Water
sign We Haut Date
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