HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 165 FOREST STREET 4/28/2021 Commonwealth of Massachusetts ' 'E;Vzo
City/Town of ,qpR 2820
21
Form 4
System Pumping Record To;,",,�
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DEP has provided this form for use=by local Boards of Health. Other forms may beused, 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
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1. System Location: Left Mg,ht'front of house, Left/Right rear of house, Left/right side of house, Left
Right side of building, Le Right rout of-buildirig, Left/Right rear of building, Under deck
Address
City/Town V state Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State _ p
Telephone Number
B. Pumping Record _
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? ❑ CIW 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. Location where contents-were disposed:
Lowell Waste Water
Signitute 4 HaulerU Data
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