HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 360 FOREST STREET 4/1/2020 Commonwealth of Massachusetts qp�
City/Town of row 7,2
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System Pumping Record '4S446,o°Rrtiy Zo
Form 4 FpgRT�Np���R
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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/ i ht front co h�'Left/Right rear of house, Left I right side of house, Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town Stat
Z-��, Zip Code
Telephone Number
B. Pumping Record
7
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Ic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes awo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Systerm
6. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Lk-S.
nts were disposed:
G Lowell Waste Water
Sign Date
t5form4.doca 06/03 System Pumping Record•Page 1 of 1