HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 536 FOREST STREET 4/23/2020 ..� Commonwealth of Massachusetts RECEIVED
City/Town of APR 21 202M
OF NUR I H
System Pumping Record TOWN
OHEALLTH DEPARTMENTER
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms maybe'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/ g front of house, eft/Right rear of house, Left/right side of house, Left
Right side of building, L ding, Left/Right rear of building, Under deck
Address
cityRown State Zip Code
2. System Owner. L_0 - ft
Name'
Address(if different from location)
Cit)fTown State Tip Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2 Quantity Pumped:
Gallons
3. Type-of system: ❑ Cesspool(s) [I-Septic-Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes (3--N __�_ If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Sjrstem: �� �--
I� �
6. System Pumped By:
Neil.Batesbn F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo i here contents-were disposed:
L S Lowell Waste Water
SigniWe it Haul Date
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