HomeMy WebLinkAboutSeptic Tank - Septic Pumping Slip - 327 FOREST STREET 5/17/2021 : Commonwealth of Massachusetts 'D
City/Town of p'�1
System Pumping Record
Form 4 10 ' ��`
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
focal 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 house, Left[Rigtit rear of house,'Left/right side of house, Left
Right side of building, Left/ Right front of building, Left/Right rear of building, Under deck
Address
City(rown State Zip Code
2. System Owner.
Name
Address(if different from location)
City/Town State:__ Zip Co
Telephone Number
B. Pumping Record �--
1. Date of Pumping Date 2- Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System: JC�c
6. System Pumped By:
Neil.Bates-on F5821
Name Vehicle license Number
Bateson Enterprises Inc
Company
7. Lo ere contents were disposed:
Lowell Waste Water
6
4n9tHauf eV Date
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