HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 704 FOREST STREET 10/7/2020 RECEIV tv
Commonwealth of Massachusetts oC1 7 2020
City/Town OI T00 01 t DEP R T R
System Pumping Record
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.fhis form,check with yotir
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 . Lew/Right ont of , Left/Right rear of house, Left/right side of house, Left
side of bu� building,
Right g, Left/Right front of Left/Right rear of building, Under deck
Address
C!Wrown State Zip Code
2. System Owner. ,`/\ .;
Name
Address(if different from location)
Civrown State Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2��Q antity Pumped- 6�lons
3. Type of system: ❑ Cesspool(s) 0-Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes Ly'No 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. LocatipAwhere contents-were disposed:
2 Lowell Waste Water
SignAtufe qt HauleU Date
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